My Digital Twin Is Worth More Than I Am

It used to be said that the human body was only worth pennies, based on its minerals (although that has been updated to $160),  If one counts the value of our organs, the figure is several hundred thousand dollars.  And, according to other estimates, if one includes the value of our DNA and bone marrow, a human body is actually worth close to $46 million.

The funny thing is, other people seem to get all the benefit.

What started me thinking about this was a report from MobiHealthNews on the FTC's PrivacyCon, particularly a discussion about the monetization of consumer health data.  We talk a lot about Big Data, but it is worth remembering that Big Data is made up of lots of little data from people like you and me.

Companies are keen to make money from the data they collect about/from us.  The Economist Intelligence Unit just released The Business of Data on this topic.  Some of its key findings

• Over 80% of surveyed organizations are taking steps to generate more value from their data.
• 60% are already generating revenue from their data.
• Over 50% are selling or buying data.
• 86% say their customers trust them with their personal data, although only 34% think they are very effective in being transparent about their use of it.
• 82% believe they are effective about keeping their data secure, although 34% admit to having had a significant breach within the past 12 months.

The apparent discontinuities in those last two bullets would be amusing if they weren't so scary.

The Pew Research Center also just released a new report, Privacy and Information Sharing.  They found consumers have mixed attitudes towards sharing their data; "it depends" was the prevailing attitude when evaluating various sharing scenarios.  They often see benefit in giving up some of their privacy -- we love "free"! -- but worry about how their data will be used and by whom, especially given the risks of security breaches.

One of the scenarios Pew presented was having your doctor upload your personal health data to a secure third party site, in return for access to your medical record and easier appointment scheduling.  Somewhat surprisingly, more respondents (52%) found this sharing acceptable than in any of the other, non-health scenarios,  Those who found it unacceptable tended to cite doubt about how secure the data really would be, noting the consequences if their data was hacked.

This concern is certainly valid.  Being hacked is bad enough, but even having your data de-identified may not be enough, since whether de-identified data can stay de-identified is very much in question, as datasets get larger and analytic techniques get better.  

As a researcher at PrivacyCon said:

What we have to realize is that genetic data is the most personal data out there...We also know this data is inherently identifiable.  There's growing recognition that it is not possible to de-identify this data in a way that is not possible to re-identify later.  The other thing is, this data is irrevocable.  If there's a privacy breach, you can't change it.  It's not like your iTunes password.

We're increasingly in a world of biometric screening and DNA sequencing (including DTC sequencing).  We are starting to use biometrics as a form of identification, as DNA has been used for many years, most notably in law enforcement.  We've gotten used to the prospect of identity theft when it comes to our financial information, but it takes on even more ominous connotations when it comes to our genetic and health information.

In a very real sense, we are our data, with DNA a fantastically effective means of storage.  Having this data stolen is especially troubling.  I wouldn't want to suddenly run into my clone.

One way or another, Big Data is posed to become a huge market.  Pharma in particular stands to benefit, with Big Data potentially revolutionizing drug development and targeting.  All of this relies on our data.  We may directly benefit from our sharing, or the benefits may accrue to other patients, particularly future ones.

Many people (including President Obama) believe precision/personalized medicine is the future of health care, tailoring treatments and even diet to a person's specific make-up.  The success of this depends on Big Data.  The President has also pushed for a "moonshot" to cure cancer, and many feel that not only does this need Big Data but also that lack of sharing data has been one of the big problems in cancer research (and, indeed, in all clinical trials).

GE's Digital CEO Bill Ruh believes that a detailed software model of a person, which he calls a "digital twin," will become integral to health care (as well as to products in other fields).  As he said,

I believe we we will have a digital twin at birth, and it will take data off of the sensors everybody is running, and that digital twin will predict things for us about disease and cancer and other things.  I believe we will end up with health care being the ultimate digital twin.  Without it, I believe we will have data but with no outcome, or value.

Whether we like it or not, whether we realize it or not, monetization of our data is happening,  While research suggests we are overwhelmingly willing to share our health information for research, once the implicit value of our contributions becomes clearer, that willingness may be more conditioned upon an explicit return.

Take, for example, Datacoup.  They are one of the first companies to allow consumers sell their data.  Consumers upload their data to Datacoup, which then markets it to data purchasers, with the consumers getting paid based on how much those purchasers pay.  Datacoup's CEO told the EIU: "If merchants are willing to provide value in exchange for more or better consumer consented data, then you’ll see a vibrant and massive marketplace spawned for the direct exchange of data, and in effect a more direct relationship between consumers and merchants."

I'm all for pooling our data to figure out better ways of helping people, but I'm less sure that I should be doing that for free, especially given the risks of my data being stolen or used for purposes I didn't intend.

If our digital twins are going to have economic value -- as they no doubt will -- shouldn't we share in that?

Self-Driving Cars As The Future of Health Care

I'm a sucker for driverless cars.  I've only owned cars with manual transmissions, and in recent years I've been telling people that I'm more likely to jump straight to a self-driving car than to simply get an automatic transmission.  There's lots going on in the field these days, but what caught my eye was a new report from KPMG that forecast the number of auto accidents could drop 80% due to autonomous cars, shrinking the auto insurance industry by some 60%.  They are not alone in these kind of predictions.

We should be talking about those kinds of changes for health insurance, and health care more generally.

Most of us drive, and most of us probably think we're good drivers -- it's all those other bad drivers! -- but over 90% of auto accidents are caused by human error.  No wonder; there are so many other things we'd rather be doing, like texting or talking on our phone.  Maybe even checking our destination on Yelp or Google Maps.  They even have a name for this -- distracted driving -- with plenty of grim statistics that you'd think would deter us, but which do not.

Google has gotten lots of press for its driverless car project, but we've been heading this direction for some time.  For example, cruise control and anti-lock brakes have been routine for decades, but now there are also self-parking cars and ones that can alert you when other cars or objects are too close.  Tesla is in beta with a feature to let your car essentially valet itself (although they've already had to put further restrictions on it), and Elton Musk thinks fully autonomous cars will be ready in 2-3 years.

All this is in line with KPMG's prediction that by 2025 we'll be in an autonomous car world, with consumers shifting over to it by 2040.  That's when the auto insurance industry will be in big trouble, at least in its current form.

The industry executives KPMG surveyed aren't worried yet.  Only 29% felt they were very knowledgeable about autonomous cars, with 23% claiming to know nothing about them.  Most felt that their business wouldn't be impacted for at least ten years.  When the changes come, the executives thought that their focus would move more towards commercial, instead of personal, auto lines, and they expected new competitors would include tech companies like Google and the auto manufacturers themselves.

Perhaps it is no surprise, then, that GM just invested $500 million in Lyft, hedging its bet not only on a self-driving world but one where car ownership shifts to the "Uber" (sorry, Lyft!) model where cars are available on demand, with someone else doing the driving.  That model really disrupts the traditional auto industry, as it removes much of the personal attachment most of us have historically felt about our cars.

Once it isn't our car and we're relying on another driver anyway, do we really care if that driver is the car itself?  We just want to get where we're going safely, and, oh-by-the-way, more cost-effectively.

It won't just be the auto insurance industry that will be impacted by these trends.  The whole ecosystem will be: car manufacturers, parts manufacturers, repair shops, rental companies, gas stations and oil companies, and advertising agencies. to name a few.  The changes will be bigger than we realize and sooner than we expect.

All that is very interesting, but what does it have to do with health care or health insurance?

When it comes to managing our health, we're not much better than we are with our driving.  We weigh too much, we eat the wrong things, we don't get enough exercise or sleep, we have too much stress, and when we do get medical care, we often don't listen to or understand our doctors, or simply don't follow their instructions.  If any area of our lives seems like it needs someone/something to take over for our (poor) judgement, it would seem to be in regard to our health.

We might think those auto insurance executives who believe they have ten years to get ready are being short-sighted, but no one in health care should be feeling any better about its existing model.  The seeds for similar disruption are already here for health care as well.

Telemedicine, AI advice, digital tracking, and consumer diagnostic tests -- all these are the kinds of things that have the potential to take the locus away from your friendly local physician/hospital/lab/pharmacy/imaging center.  They are slowly working their way through the laborious regulatory system and the consumer acceptance stage, just as they are for autonomous cars and the ride-sharing industry.  But it would be foolish to believe that they won't become mainstream.

Of course, short of uploading our minds to live inside an android or a robot, it would be hard to fully delegate our health to some third party.  I've previously made a pitch for an omnipresent digital health assistant that would help guide us to better health choices, but we're not quite there yet.

That's why perhaps wearables/digital health are the most likely bet in the short term.  We're seeing traditional tools like stethoscopes being replaced by digital options, lab testing being ordered by, and results delivered to, consumers, and an array of other self-monitoring options.  Two-thirds of Americans say they are willing to use digital health tools.

Products like Apple Watch, Samsung Gear, or Fitbit are all doing their best to be a ubiquitous and value-added presence in our lives.  Whether they can actually help us improve our health remains to be seen, with early results indicating...maybe.

Health care professionals think that their revenue can only go up -- here's looking at you, drug companies! -- but I'm convinced that well before the auto insurance industry suffers its big decline in revenues, health care will have already done so.

We've used "consumer-directed" as shorthand for making consumers responsible for more of the bill and "patient-centered" as shorthand for getting all the various health care professionals involved in delivering a patient's care to talk to each other, but in both cases without truly changing any of the fundamental dynamics.  Perhaps the real parallel to driving is not handing management of our health over to some third party -- which we've done too much of already -- but in actually taking control of it.

When it comes to health, the "self-driver" is us.

What If They Are Right?

Let's say you have a product that you just can't get the public to want.  You market the heck out of it, you sell a bunch of different versions of it, and you warn people about how their lives could be ruined if they don't buy it, which, in fact, isn't untrue.  You even manage to get the government to require people to buy it, and also to provide subsidies for them to purchase it.  Yet still the customers you want most remain stubbornly uninterested.  At some point most people would conclude it isn't a marketing problem but a product problem.

When the product is health insurance, though, we tend to think those who won't buy it are short-sighted and even irresponsible -- but what if they're right?

The New York Times just reported that many Americans find that it is cheaper for them to pay the fine for not having health insurance than it is to actually pay for health insurance, despite increasing fines, subsidies for the purchase, and the presumed financial benefits of having health insurance.  It cites a recent Kaiser Family Foundation analysis which found that there are some seven million such uninsured Americans.  As one resister told the Times, "I don’t see the logic behind that [buying coverage], and I’m just not going to do it."

The article gave examples of several consumers who were surprised -- in one case, "offended" -- that the plans featured large deductibles that would require them to pay the initial several thousand dollars of medical expenses.  If something truly catastrophic happened, one claimed: "I feel like it’s better just to die."

Maybe not such a great strategy.

It's not that there aren't some positive signs.  NCHS data indicate that the number of uninsured has dropped from 45 million in 2013 to 28.5 million for the first half of 2015.  Sarah Kliff reports that people under 35 account for 35% of healthcare.gov's open enrollment sign-ups, versus 33% in 2014, with close to million new enrollments from that demographic, versus under 700,000 a year prior.  Not wanting to pay the penalty motivated their enrollment more than older enrollees.

The NCHS also reported that the number of people under 65 who had problems paying medical bills in the past 12 months decreased from 56.5 million in 2011 to 44 million in the first half of 2015.  The percentage varies by insurance status (29.8% for uninsured, 21.8% for those with public coverage, and 12.2% for those with private coverage) and income (24.5% for the poor, 27.1% for the near-poor, and 12.2% for the not-poor).

Still, 28.5 million people remain without coverage, 44 million are having trouble paying medical bills, even among those with private insurance or "not-poor"...gosh, that doesn't seem like a raging success.

A couple other articles have deepened my belief that we've gone down the wrong path:

• A new study, as reported by The New York Times and with some additional observations in Health Affairs, confirms the long-known wide ranging pricing and utilization in the U.S.  What's new is that Medicare spending is not necessarily linked to private insurance spending -- "lower cost" markets for one does not automatically result in lower costs for the other.  It also reaffirmed that prices vary wildly not just across markets but within markets, even for negotiated insurance rates.    
• A new study found that our convoluted patent/FDA approval system makes it more financially advantageous to invest in cancer drugs that extend cancer patients' lives by a few months instead of on drugs that might prevent cancer.  Huh?

This is not all the fault of health insurance, but it has had a role.  We entrusted public and private payors with negotiating on our behalf with health care professionals and industries.  As it turned out, it was easiest for them to do within some arbitrarily narrow definitions, limiting who can be paid how much for what.  Our "health" system is a medical one.

The end result is this system where prices vary irrationally even when one has insurance, where the care you get is a function of which provider you get it from rather than what is best, and where we spend more than any other country and certainly more than many of us can afford.  The end result is that the same kinds of entities that were getting the biggest share of our health care dollar in 1960 are still getting about the same shares now (as I discussed previously), which sure seems like some kind of a sweetheart deal to me.  

It seems foolhardy to self-fund oneself in a world where a lengthy hospital stay or drug regime can easily bankrupt anyone other than the so-called 1%, yet health insurance allows and, to some extent, exacerbates that kind of expensive treatment.  It has become part of the problem.

Look, I worked in the health insurance industry for a long time.  I helped introduce consumer-driven/high deductible plans to help foster cost-awareness.  I bought into the protection-against-big-expenses meme.  I personally have never not had health insurance.  So, by most standards, I should be biased in its favor.  But I'm beginning to wonder if health insurance itself is the problem, or at least a big part of the problem.  

I've written before about some of the new entrants into health insurance; more power to them, and the more the merrier.  What I continue to be disappointed by is that we're not really seeing fundamentally new approaches to what health insurance is.  Going back to the product analogy above, we're just iterating versions of the iPod instead of introducing the iPhone.  We probably would have continued to love our iPods if the iPhone hadn't come along, but not many of us would opt for a world that had better iPods but no iPhones.

I wish I knew what the alternative to health insurance was.  I wish I even had a good idea for an idea for it.  The closest I've come is a thought experiment I posed some time ago, where we crowdsourced any help we wanted for our health spending, which would be subjective and unpredictable, but which would at least open our eyes about who is paying for our care.

Here's a radical suggestion: instead of thinking of more ways to force people to buy health insurance they don't want, we should be developing products to protect their heath that they actually want to buy.

Better Think Again

Usually this time of year people like to either look back at significant events of the year just ending, or to prognosticate about what might happen in the new year.  Well, neither my rear view mirror nor my crystal ball are quite that good, so I'll use my last post of the year to cite some examples of the kind of innovations that most fascinate me, ones that suggest the future may come sooner and/or be quite different than we expect.

Or maybe they'll prove to be red herrings.  It's hard to say.

I'll give three examples.  How and even whether any of them relate to health care, we'll get to later.  In no particular order:

Tell me your password:  If you go online with any regularity, chances are good that you've got a password.  Probably, in fact, a whole bunch of them.  With online security becoming ever-more important, more sites require passwords, and tougher/harder-to-remember ones at that.  The trouble is keeping track of them all.

People use different strategies to deal with this ever-growing plethora.  Some people have good enough memories to recall them all, although I don't know any such people.  Others create lists to keep all their passwords, or utilize apps to store and even create passwords for them.   Ironically, those apps themselves require a password, which creates kind of a cat-chasing-its-own-tail scenario.

But passwords are so 1990's.

Google and Yahoo, separately, are testing getting rid of passwords, replacing that step with a message sent to your smartphone, which you can use to authenticate the log-in attempt.  Of course, if you have failed to lock your phone, or have forgotten its password, you're out of luck.

Other new approaches include using fingerprints, which have the drawback that they, too, are now digital and thus can be stolen, or facial recognition, as Windows 10 now allows.  Hey, as if recognizing your face isn't enough, UK-based start-up AimBrain claims its software can recognize you by how you use your device, making passwords unnecessary.

I don't know what approach will win out, but, given how much people hate them, how poorly they use them, and how easy they are to hack, I'm willing to bet that in five or ten years we won't be using passwords.

Give me the cash:  We love our credit and debit cards.  Not all that long ago, it seems, we mostly used credit cards only for larger purchases, and debit cards not at all, but now you can pretty much use them about everywhere, for any amount.  Still, you probably go out with some cash on you, just in case.

Unless you live in Sweden, that is.

Sweden appears to be closer to a cash-free economy than just about anywhere.  According to The New York Times, cash is only used for twenty percent of consumer payments in Sweden, versus around seventy-five percent in the rest of the world (surely that is a typo, right?  75%?).   Some Swedish banks don't even keep cash on hand.  Seriously.  As one student said, "No one uses cash.  I think our generation can live without it."

In a cashless society, people use credit/debit cards, or smartphone-based approaches like Apple Pay or Google Wallet.  Those approaches still are primarily based on card networks, but don't require you to give your card info to a merchant.

Money is, after all, notational, even actual currency.  It only works because we all agree it has value, and whether it is cash or digital isn't fundamentally important.  As Bitcoin is slowing proving, "money" doesn't even need to be something issued by governments or central banks; just a bunch a people agreeing to accept it allows it to have value.

I don't know if the winner is going to be cards, electronic transfers, Bitcoins, or something else, but  in ten or twenty years you may have trouble getting a merchant to accept your cash.

Cutting the cords:  This is a hot topic.  I've written on it myself.  Instead of using a landline for telephone service, we figuratively cut that landline and rely on our mobile phone.  Instead of being forced to take whatever array of channels our cable company forces upon us, we choose our own shows or our own packages of shows, usually streaming via the Internet.

The cable companies prepared for the future by becoming ISPs, so they love broadband, which they can charge more for (despite our abysmal speeds).  The landline telephone companies are either out of business now or have become mobile carriers.  But neither may be really ready for the future.  Here's the fact that makes me think so: home broadband use is actually declining.

According to the Pew Research Center, broadband use declined from 70% in 2013 to 67% in 2015.  That doesn't sound like much, but it is statistically significant, and it is a shocking reversal of prior trends; remember, at the beginning of the century broadband use was essentially zero and was still below 50% as late as 2006.  Fifteen percent have dropped cable or satellite service; a third of younger Americans have dropped or never had pay TV.

The reversal is attributed to more people thinking that kind of connectivity is too expensive, especially when thy can get much of the content on, you guessed it, their smartphones.  

All this sounds bad for cable but surely good for the mobile telephone companies, yet they shouldn't get too cocky.  We may not need them either.  Google has launched Loon -- "balloon-powered Internet for all" -- while Facebook is using drones to accomplish the same.  Right now both giants are testing these approaches in rural or third-world areas, but to the extent they succeed they will certainly help change the paradigm.  

Cable and mobile phone companies should remember that consumers' using the Internet through them was, in some ways, a fortuitous happenstance, and that if they are too greedy -- how much are those packages and data plans? -- or too shortsighted, the future may no longer include them.

In 20 or 25 years, cables and mobile phone networks may be as outdated as analog broadcasting and television antenna are now.

OK, so these examples may not be about health care, or may only impact health care in the same way they impact other industries.  The importance of them, to me, is less in their direct applicability as in their reminding us that the world -- even for health care -- doesn't always evolve incrementally or even predictably.

And I love that.

Oh, And It Is Also An EHR

You wouldn't -- I hope -- still drive your car while trying to read a paper map.  Hopefully you're not holding up your phone to follow directions on its screen either.  Chances are if you need directions while you are driving, you'll be listening to them via Bluetooth, glancing at an embedded screen on your dashboard, or maybe looking at a heads-up display on your windshield that doesn't even make you take your eyes from the road.  Or maybe you're just riding in a self-driving car.

But when it comes to your doctor examining you, he's usually pretty much trying to do so while fumbling with a map, namely, your health record.  And we don't like it.

A study in JAMA Internal Medicine found that patients were much more likely to rate their care as excellent when their physician didn't spend much time looking at their EHR while with them; 83% rated it as excellent, versus only 48% for patients whose doctors spent more time looking at their device's screen.  The study's authors speculate that patients may feel slighted when their doctor looks too much at the screen, or that the doctors may actually be missing important visual cues.

Indeed, a 2014 study found that physicians using EHRs during exams spent about a third of the time during patient exams looking at their screen instead of at the patient.  It is a dilemma; the records hold important information, and inputting new information is generally thought to be more accurate when done at point-of-care rather than at some point after the exam, so doctors are damned if they do and damned if they don't.

As one physician told the WSJ, "I have a love-hate relationship with the computer, with the hate maybe being stronger than the love." 

No wonder that the president of the American Academy of Family Physicians says: "We've taken this technology and we've embraced it, but I think a lot of us don't believe it's ready for prime-time. We've got this interloper in the exam room, but it's not there to help with the medical side as much as it's there to check boxes for insurers."

I might quibble that the familiar physician shibboleth about EHRs being there to serve insurers' purposes rather than to improve care perhaps is one reason why they are not ready for prime time, but I certainly don't dispute the fact that they are not.  After we've spent the past several years and over $30b of federal incentives to persuade physicians to adopt EHRs, physician satisfaction with them appears to be declining.

Know any health care professionals who rave about their EHR like they do their iPhone?

The problem is that we forget that the record is not the point.  It wasn't the point when it was on paper, and putting it in an electronic format doesn't make it the point.  The information in it is a tool -- just a tool.  It is supposed to help the physician diagnose the patient, and record what happens to the patient, so he/she can be better diagnosed in the future.  Figuring out what is wrong with a patient and what to do about it is the point. 

Paper records were siloed and made the physician draw his/her own conclusions without providing any assistance.  EHRs have the potential to draw data from larger patient populations, even if they don't yet do so very effectively, and can also give some assistance to physicians, like warning about drug interactions.   But working with them still involves looking at too many screens and having to populate too many boxes.  No wonder physicians are employing scribes. 

Don't get me started on medical scribes.

Let's picture a different approach, one that doesn't start with paper records as its premise.  Let's start with the premise that we're trying to help the physician improve patient care by giving him/her the information they need at point of care, when they need it, but without getting in the way of the physician/patient interaction.

Let's talk virtual reality.

Picture the physician walking into the office not holding a clipboard or a computer or even a tablet.  Instead, the physician might be wearing something that looks like Google Glass or OrCam -- not a conspicuous headset like Oculus but something unobtrusive (a concept that investors are already pouring money into developing).  There might be an earbud.  And there will be the health version of Siri, Cortana or OK Google, AI assistants that can pull up information based on oral requests or self-generated algorithms, transcribe oral inputs, and present information either orally or visually.

When the physician looks at the patient, he/she sees a summary of key information -- such as diabetic, pacemaker, recent knee surgery -- overlaid on the corresponding portion of the patient's body.  Any significant changes in blood pressure, weight, and other vitals are highlighted.  The physician can call up more information by making an oral request to the AI or by using a hand gesture over a particular body part.  List of meds?  Date of that last surgery?  Immunization record?  No problem.

The physician can indicate, via voice command or hand gesture, what should be recorded.  It shouldn't take too long before an AI can recognize on its own what needs to be captured; the advances in AI learning capabilities -- like now recognizing handwriting -- are coming so quickly that this is surely feasible.  Keeping an EHR up-to-date should be child's play compared to, say, beating Ken Jennings at Jeopardy! or Gary Kasparov at chess.

In short, the AI would act as the medical scribe, without the patient even realizing it or the physician having to worry about it.

More importantly, the AI could quickly pull up/synthesize any pertinent literature, or assist the physician in coming up with a diagnosis and/or treatment plan -- as Watson is already doing for cancer.  Maintaining and presenting the EHR are the finger exercises, if you will; helping the physician deliver better care is the main function.  And without intruding on the physician/patient relationship.

Building better EHRs is certainly possible.  Improving how physicians use them, especially when with patients, is also possible.  But it's a little like trying to make a map you can fold better while driving.  It misses the point. 

We need a whole different technology that subsumes what EHRs do while getting to the real goal: helping deliver better care to patients.

It's a Doc's Life

There is an old expression "it's a dog's life" used to describe a life that is hard and unpleasant.  That expression is probably outdated; most dogs seem to live pretty comfortable lives.  Based on recent research, though, maybe we should be saying "it's a doc's life" instead.

It has kind of a certain ring to it, don't you think?

Let's look at some of the new research, starting with a study by the Mayo Clinic.  They updated a survey they did in 2011, and found a number of disturbing issues, including:

• More than half (54%) of physicians report at least one symptom of burnout.  That compares to 45.5% in 2011.
• Only 41% of physicians reported being happy with their work-life balance, compared to 48.5% in 2011.
• Physicians fared worse on both burnout and happiness with work-life balance than the overall population, even adjusting for age, gender, relationship status and hours worked.
• Pretty much every specialty showed declines on both burnout and work-life balance.

The authors believe that American medicine is at a "tipping point" due to the burnout and lack of work-life balance, and that there is an urgent need to address the underlying causes.  It'd be hard to disagree with them.

The study would be disturbing in its own right, but it is not the only such study that showed up just this month.  A study in JAMA by Mata, et. alia found that almost 30% of resident physicians reported depression or depressive symptoms.  As one of the authors said:  "What we found is that more physicians in almost every specialty are feeling this way and that's not good for them, their families, the medical profession or patients,"

No kidding.

The study was a meta-study, analyzing results of other studies, and the prevalence ranged from 21% to 43% in the various studies, so the 30% may be conservative.  As with the Mayo study, the problem appears to be getting worse, with the results showing a slight but statistically significant increase over the five decades analyzed.

An accompanying editorial called resident depression "the tip of a graduate medical education iceberg."  It notes that training itself has changed little from the 1950's or 1960's, while "the actual delivery of medical care in 2015 would be unrecognizable to those same physicians."  New care options and resulting ethical dilemmas, more pressures on reimbursement and on demonstrating value, malpractice concerns, EHRs, and increased patient demands create a world that the graduate medical education system leaves residents ill-equipped to deal with.

The editorial calls for a fundamental rethinking of our approach to the graduate medical education system.  Again, it'd be hard to argue with that conclusion (and the rethinking shouldn't be limited to graduate medical education).

If any further evidence of a problem was needed, the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians provides some.  I'll leave the international comparisons for another day, but I was struck by a few of the findings for U.S. primary care physicians.  Twenty-four percent report not being well prepared to manage patients with multiple chronic conditions.  Less than half are well prepared to handle patients needing palliative care or long term home care, or patients with dementia.  And less than a third are prepared for patients needing social services, those with mental health issues, or those with substance use issues.

Given that one in four of American adults have multiple chronic conditions, one in five have mental health issues, and about one in ten have substance use issues, well, I'd say primary care physicians should be pretty worried.

No wonder that only 16% of those U.S. primary care docs think our health care system works well (which was, by the way, by far the lowest across the 10 countries), or that 43% report their job is very or extremely stressful.  No wonder they're getting burned out.

Despite the above findings, another JAMA study found that at least one kind of primary care physician -- family practice residents -- still had high hopes.  Family practice residents reported that they planned to provide a broader scope of services than practicing family practice physicians, such as prenatal care and inpatient care management.  Whether that is recognition of a changing role or simply naive expectations remains to be seen.  As one of the authors told Reuters, "it may be that the previous generations have had these same intentions and for numerous reasons are not able to practice the way they intended."  

In other words, real world, meet residents.  Residents, real world.  Try to get along.

Look, I get it.  Being a physician is not what it once was.  No more physician-as-God, no more white coat mystique.  Their business model has radically changed from largely independent artisans to more typically being employees with productivity expectations, whose judgement is constantly challenged by patients, payors, administrators, and/or lawyers.  That must be hard to accept.

But, then again, I don't know many people who don't think their job hasn't changed significantly in the past twenty years, with more pressure, higher expectations, 24/7 demands, and more reliance on technology.    Physicians can rightfully argue that their role is different in that people's lives depend on their decisions, but other professions -- e.g., police officers, air traffic controllers, even civil engineers -- could claim the same.  

It's tough all over.

We should be worried that physicians are depressed.  We should be worried that they feel burnt out.  We should be worried that they don't feel ready to manage the kind of complex patients they are seeing more of.  These are problems that need to be recognized and addressed.  But the life of the physician isn't going back to what it was in the 1960's, and that is not a bad thing.  

It should be a great time to be a physician.  We've never known as much about what causes various health issues, never had as many diagnostic tools, never had as many treatment options, and never had as much potential for people to be educated about their health and to be an active participant in their care.  If all that isn't exciting to someone, perhaps being a physician isn't the right profession.

For what it is worth, both medical school applicants and enrollees have reached record levels.  Let's hope they're not in for a big disappointment when they find out what a doc's life is really like.

The White Coats Are Coming! The White Coats Are Coming!

Let's say you were in a social setting, or even some business settings, and you introduced yourself to someone using your first name but that person's response was to introduce himself/herself using their last name and a honorific.  You might think they were oddly formal.  If, in those same settings, someone greeted you by your first name while introducing himself/herself using an honorific and his/her last name, well, you might think he/she was stuffy, if not a jerk.

Yet this happens all the time in health care settings.

Now, in the past, I've been critical of the use of the term "patients" to describe us laypeople in the health care system, arguing that it connotes a certain passive, secondary status about us.  Ashley Graham Kennedy, a philosophy professor at Florida Atlantic University, goes me one further: in a BMJ opinion piece, she asserts that "the title 'doctor' is an anachronism that disrespects patients."

How about that?

Professor Kennedy cites situations where doctors introduce themselves as doctors while not taking into account their patients' own professional titles.  How many of us have had a physician casually use our first name while expecting us to use their title?  If we happen to be sitting on an exam table or in a hospital bed wearing a gown that leaves us half exposed, the asymmetry is even more pronounced.

She notes that we don't need titles or even white coats -- more on that in a bit -- to figure out who our caregivers are or what their role in our care is.  More on point, she argues that the title is an explicit expectation that we are to treat them with respect, due to the training that the title signifies, whereas respect is something that deserves to be earned, such as by how we are treated.

It is the 21st century after all.  We know that not all physicians are equal, that not all medical education and training is the same, and that not even physicians know everything, even within their specialty.  If we're supposed to automatically respect all physicians, it better work both ways.

Personally, I don't mind calling a physician "doctor," although if he/she calls me by my first name (which I'd prefer) I'd expect that to be reciprocal.  What I wonder is what the title really means anyway.  There are a lot of "doctors" out there.  If someone introduces themselves as "Dr. X," you don't know if that means an M.D./D.O., or if it means DDS, DMD, DC, DPM, Pharm.D., DVM, OD, Au.D, Ph.D or ScD.  I'm sure that list isn't even complete, even within health care.  So as a means of automatically signifying respect for our physician, it's a pretty poor marker.

Some of the reactions to Professor Kennedy's argument are even more interesting.  While she believes that the deference the title expects is incompatible with patients being equal partners with their physicians, some respondents -- who usually seem to be physicians -- argued that the supposed partnership is not, in fact, equal, since physicians' training and experience makes them experts in a way patients can never equal, no matter how much Internet research they do.

I think those kind of responses kind of make Professor Kennedy's point.

The doctor/patient relationship is at its most asymmetrical when there is some acute event -- e.g., we have a heart attack, we need our appendix out, we need chemo.  But with more of our health care spending going to chronic conditions that, in many cases, are linked to lifestyle choices, the asymmetry is greatly reduced, and physicians should think twice about assuming they know more about maintaining our health, especially if they can't demonstrate that they "practice what they preach" when it comes to those kinds of healthy choices.

If the title "doctor" is a verbal indicator of expected respect, the white lab coat is a tangible one.  Almost all U.S. medical schools bestow one as part of their graduation ceremony (although this tradition is, surprisingly relatively new).  The fashion of physicians wearing them had to do with the (belated) acceptance by the medical establishment in the latter part of the 19th century that, yes, germs mattered; the coat was to suggest they kept their environment as sterile as in a lab.

Ironically, of course, the white coat itself may (or may not) be a carrier for germs, which has led the NHS to adopt a "bare-below-the-elbows" policy.

This is, apparently, a hot topic.  There are more issues than one might have imagined, including what physicians think patients want and -- my favorite -- how cartoons would portray physicians without a white coat.  Another opinion piece in BMJ bemoaned how the NHS "bare-below-the-elbows" policy has led to "scruffy doctors," urging them to "put your ties back on."

Not everyone agrees that the more casual attire leads patients to view doctors as scruffy and thus possibly lacking in hygiene.  (Dr.) Phillip Lederer wrote an excellent article on the controversy recently, reminding physicians that they'd still be a doctors even without the white coat.  He concluded: "There is no harm in avoiding white coats, but there could be danger in wearing one."

That would seem like the killer argument, but apparently it is not.

I mean, really, I can see wearing a white coat if the physician actually works in a lab, such as a pathologist, but it is hard to see it as much else other than a status symbol if they are actually seeing patients.  Health care is full of status symbols, including not just the white coats and automatically calling physicians "doctor" but also those nice parking spaces reserved for physicians that patients and their families often have to walk past, or, for that matter, major donors getting their names on health care buildings.

We shouldn't take any of them more seriously than if, say, all physicians started wearing monocles to further model those 19th century physicians.  The point is, it's not supposed to be about their status, but about our health.

Paul Revere may have never actually shouted "The British are coming!  The British are coming!" but he did help herald a revolution.  Maybe by rethinking some of the traditional status symbols in health care we can signal a revolution of our own, fighting for a health care system in which we are more responsible for our own health and are expected to be more equal partners with the people who help us with that.

Or we could try the monocles.