NEJM: Bizarro Regulatory Suggestions

The two leading perspective articles in last week's New England Journal of Medicine are striking examples of the bizarre call for regulation when none is need.

The first, Kevin Outterson's Regulating Compounding Pharmacies after NECC is a lawyer's take on changes in the regulatory requirements after the New England Compounding Center fiasco in which hundreds of people were infected with rare fungal disease due to contaminated steroids.  Compounding pharmacies are an interesting entity in modern medicine.  In a time when drug companies and generic manufacturers are stamping out medicines left and right, it is the compounding pharmacy that is allowed to take existing medicines and combine them (or redose them) due to individual physician/patient needs.  Due to their unique role as the individual practice of pharmacy, they have avoided wide-scale regulation like their manufacturing counterparts.   Apparently Congress is already discussing new federal regulations.

However, as Outterson clearly points out, there are State AND FDA regulations in place (that were violated) leading up to these events.  In fact, Massachusetts and the FDA had begun investigating NECC as early as 2002.  He laments that the already overburdened FDA oversight leaves limited opportunity for proactive oversight due to elements of the current rules that were not passed.  Again, the FDA had knowledge of problems at the NECC 10 years prior to the events.  So it would seem that the problems are not a lack of regulations, but the enforcement of existing regulations.  How the passage of new regulations will do anything but punish those already in compliance with additional burdens without catching violators is beyond me.  I guess it is easy to write rules and hard to enforce them, so we might as well keep writing rules and hope that solves the problem.

In a second, Cerreta et al's Drug Policy for an Aging Population - The European Medicines Agency's Geriatric Medicine Strategy reports on the EU's Medicines Agency strategy for evaluating (and theoretically changing) its regulatory strategy in the "development, approval and use of medications."  This process, which started in 2006 produced a strategy 5 years later recognizing that:

1. The elderly use most of the medicines
2. Chronological Age alone is inadequate for characterizing frailty ("young old" vs. "older old")
3. Investigators tend to cherry pick patients often making the results non generalizable
4. Patients have different preferences and clinical scenarios leading to individual risk/benefit decisions
5. Hard to open packages are hard to open
6. Package inserts are hard to read
7. Drug-Drug interactions are only likely to be picked up after the drug is in use

These are shocking conclusions, certainly worthy of such time and investment.  Furthermore, does this not all fit entirely within information that any producer of a product would like/need to know, and improve upon where possible?  In the backwards world of medicines, product innovation is best preceded by a "regulatory framework."  Because top down innovation has such a clear track record of success.  What could have been done if manufacturers (and new entrants!) had spent the last 5 years free to innovate based on the assumptions above, none of which are particularly ground breaking, nor dangerous enough to require evidence before action.  From the regulators seat, it must be preferable to spend years and untold amounts of money while preventing possible good for millions in order to prevent embarrassing and scandalous possible harm for a few.

And we wonder why our health care is bureaucratized, inefficient, inhuman and unable to innovate itself in over 50 years...

New England Journal of Medicine: The Health Care Jobs Fallacy

In a recent New England Journal of Medicine Article entitled The Health Care Jobs Fallacy, Drs. Baicker & Chandra question the very popular public policy assumption that growth in health care jobs is a positive economic indicator.  The article is a quick read, and begins strongly by questioning a core fallacy that more jobs means a stronger economy.  The very existence of a job does not imply that any value is actually being created, makes no comment on the efficiency of the expenditure, or if the person doing the job could be doing something more productive with his or her time.  Overall a bold move by the authors and NEJM to challenge common (and flawed) political wisdom.

However, the authors retreat from their strong opening as they maintain the position that health care is necessarily a uniform, society-wide service and must be viewed through the scope of central planning.  Talk about "losers and winners" and the boilerplate closing disclaimer paragraph (go slow, wait for evidence and expand other programs) echoes fixed-pie rhetoric that is typical of the pubic policy world.    


Working in the innovation space, I continue to lament the notion of many of my very intelligent colleagues that we can centrally design one simple health care system for all, despite the litany of failures evidencing the contrary.  It will be interesting to see how the ACA plays out, but I have little faith that any centralized attempt to "fix healthcare" will produce anything other than the complex, inhuman, politically charged system that it has already produced-- only larger, more consumptive and more toxic to innovation as it grows.  


A commendation to the authors for taking on this politically unpopular reality, and I hope that the net effect is not a subtle shift in the metrics of public policy, but a broader view of health care that puts patients (that would be all of us) and the subset of patients who act as caretakers & providers in charge of guiding the direction of this incredibly important and dynamic service. 

On Being Nice

As you may know, I have been spending a great deal of the last 6 months in Las Vegas, working with an amazing team to get the Culinary Extra Clinic up and running.  This is the first Iora Health practice that we have opened, and it has been a whirlwind.  Amongst the many lessons, observations, and strange moments in the trenches of health care innovation--one situation has struck me a number of times, and is frankly quite troubling:

I have been told by multiple patients, home health services, and even our call center, that I am the "Nicest doctor they have ever worked with."

Humblebrag aside, this notion actually confuses the heck out of me.  For those of you that know me, I think I am fairly pleasant and polite, as my parents taught me to be, but not the nicest anything anyone has ever met.  So I figured I am just nice compared to the competition.

I started asking folks why they thought I was nice; more specifically, how were my colleagues from the world of medicine acting towards our partners far away and in patient homes?  The answers I received were downright appalling:

From a home health nurse (roughly paraphrased): "Oh, most of the doctors don't call us back.  When they do, they are very short with us as though a patient being sick were our fault.  They usually just tell us to send the patient to the emergency room and won't speak to them. No one has ever called me back twice like you did"

From our call answering service: "Most of our doctors don't call us back.  Many who do yell at us for calling them, letting the patient through, etc."

This troubles me greatly, on professional and practical levels.  Professionally- our entire job is the care of our patients.  Here are members of the loosely defined team of care for our patients, and we are yelling at them?  In some cases, like the answering service, we are paying for a service and then ignoring those that are providing it?  Frankly this type of behavior is nonsensical, makes us look foolish, and destroys whatever sense of team and trust we have with our patients and their caregivers.  From a group of vaunted professionals, it is fairly immature behavior.

Practically-- we are really cutting off our nose to spite our face.  In the case of the home health nurse, the very existence of this service creates less work for good doctors.  If it weren't them in the patient's home, it would have to be us--a level of demand we cannot currently meet.  And the answering service?  They are able to filter and triage calls, and more importantly establish an agenda for the call with the patient and provide translation services as needed.  They will get patients on the phone for me (saving me countless attempts, phone ringing, etc.) and expedite the care of my patients in various ways.  The value of these types of services cannot be overstated.

So why be mean?  I am going to intentionally sidestep the reasons why doctors might be mean to their colleagues, because frankly, none of them are all too valid.  I am going to offer some advice, instead.

Be Nice.  Be patient, listen, and always be polite.  (Do what your parents taught you to do, or at least mine taught me).  Do these things not only because they are the right thing to do, a worthy end in itself, but because they are incredibly useful.  When you are nice to your team members, they want to work hard to care for our patients.  They think of new ideas, share information that you would otherwise miss about our patients.  They know they can rely on you, and bolstered with this confidence can take much better care of patients.

While it saddens me greatly that so many have experienced doctors so vile that I come out as "the nicest," there is a real, simple opportunity here for us to improve the practice of our craft.

Planning in the Clinic (Part 2 of 2)

Part 2 of 2 

(for part 1, see http://icu.iorahealth.com/blog/2012/05/10/planning-in-the-clinic-1-of-2/)

Cross posted from a conversation I had with the great John G. Norman over at Iora Health's ICU Blog:

In the earliest days of ICIS ((Iora's Clinical Intelligence System, our version of a medical record) planning, stakeholders and members of the product and engineering teams noticed affinities between our ideal Electronic Medical Record (EMR) system and the project planning systems used in software and design.

---

Q. You’ve taken a special interest in gaming in medical software innovation. Where is that going to take us?

A. At the guidance of our awesome product manager, Jess Kadar, I have been reading Jane McGonigal’s book Reality is Broken. Everyone should read it (parent, doctor, gamer, non-gamer, patient …) because it portends the future. Much of my thinking about why I like games comes from her work and her collection of other’s work. Gaming is defined as voluntarily overcoming unnecessary obstacles. Involuntarily overcoming necessary obstacles is called work.

The key then is to overcoming the drudgery of health care by making the work of health care fun. One of the best ways of doing this is socializing our health work. Whether through competition, leader boards, bragging, sharing, storytelling or just keeping each other up to date, there is tremendous power in games. We borrow this from Counterstrike and TF2 and Starcraft. However, what mostly fails is that the underlying game mechanics – taking pills, seeing doctors, getting mammograms – are not only not fun, but highly unpleasant. Starcraft was fun before it became the national sport of Korea. One could argue that repeatedly clicking buttons is not fun, but that is an oversimplification on what makes games games.

I think health care gaming is in its infancy because it is hard to design a game to motivate you to do something that you should already be motivated to do. Who doesn’t want to be in shape and healthy? And yet so few of us are. To try and solve that problem, early health game designers have given away a chance to win an iPad, or a trip to Aruba, or points towards purchases, effectively paying people via games to be helpful. While I think there are important ties between financial and health motivation (mostly that we give up our health for money in the form of poor/quick eating, deferred exercise and missed sleep), these games miss something important. Perhaps, getting back to the social nature of gaming, we need to reward people for getting each other healthy. I might eat a doughnut instead of winning game points, but there is no way in hell I am going to let you eat a doughnut instead of me winning game points.

Another component of non-medical games is that they are amazing at interface design. Many applications just have awful design, making you bend to the will of the designer. Not games. There is no other medium I can think of that so seamlessly sends so much data the way of the user, and has the user begging for more. There are plenty of games with bad interfaces, usually crowding the dustbins of Targets and Walmarts: I just cannot remember playing them (for very long). Contrast this with most medical software, which is just atrocious. I feel like EMR designers secretly hate doctors and wish to torture them, one check box click at a time. There is no way a game would be seriously released (and purchased!) in the sad interface state of so much medical software.

As a disclaimer I have always loved games. Since ColecoVision all the way through modern PC gaming, coming of age during the golden age of SNES RPGs, family board games (the brutal national sport of the Schutzbank household), endless chess matches with my dad (I only have 4 wins in ~26 years), pinball, etc., I have been hooked. I love the meditative state I enter while playing, the opportunity to overcome challenges, experience a story, improve skill, spend active time together with others and simply kick ass.

Q. In the O’Malley, et al., article “Are Electronic Medical Records Helpful for Care Coordination?” the authors write, “realizing EMRs’ potential for facilitating coordination requires evolution of practice operational processes” (Center for Studying Health System Change, 22 Dec. 2009). That’s a big claim. What do you think?

A. To quote Jess Kadar again: “You cannot create software to do your job for you. To write software to solve a problem, you have to know how to solve the problem.” Doctors are pretty bad at care coordination. Non-docs are even worse. Why would we think that people who either don’t coordinate care, or do it poorly, would be able to write software that makes it easy? Good words describing good processes precede good software. We have none of the above. How do you know? Just ask 4 doctors what care coordination is and expect 6 answers.

Q. They also claim “current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).” Can you describe some concrete cases where the EMR’s provision for what is billable has resulted in information loss in care coordination?

A. Every time something is documented? That is probably a glib answer to a serious question. Docs started writing notes to document interactions with patients, to communicate the day’s meeting to colleagues, future selves and lawyers. Not terrible, but patients undergo diseases and care continuously. We have hard-coded a discrete method for dealing with continuous problems. Unfortunately the note is just not good enough of technology to handle reality.

Writing a note in a modern EMR is actually a game! Like a perverse version of high stakes Yahtzee, I have to satisfy a number of categories in a number of columns to increase my note score ($). This results in multiple ways of cheating the game – check boxes, templates, copy/pasted text carried from previous notes, words/sentences added as flourish like “All other Review of Systems negative” to score points in the game the easy way. Not that we didn’t do the work, but it is hard enough to ask all of the damn questions, then write down that you did, then write down the answers, then try and make any sense of it. This really is not EMRs fault, it is actually the fault of regulators/payors abstracting what was once a research tool (the E&M code sheet) and turning into a torture device. I will try and withhold my comments on top-down bureaucratized medicine, but the billing sheet is a perfect example.

Care coordination is all about finesse. Calling a patient twice. Emailing a doctor buddy to get someone in earlier. Recognizing just after the patient left that what you just explained did not register with them despite their assurances, or even worse, remember to do something extra. Care coordination is about communication, influence, relationship building, trust and follow through. It is really hard to build software to do that, only to support the human activity. The more I think about medical records, they are ideally a great combination of a CRM and Project management tool—where each patient is both a client and a project.

Q. Andrew, thanks. And game on!

Posted by Andrew Schutzbank and John G. Norman

Planning in the Clinic (Part 1 of 2)

Cross posted from a conversation I had with the great John G. Norman over at Iora Health's ICU Blog:

In the earliest days of ICIS (Iora's Clinical Intelligence System, our version of a medical record) planning, stakeholders and members of the product and engineering teams noticed affinities between our ideal Electronic Medical Record (EMR) system and the project planning systems used in software and design.

---

Q.Andrew, one of the things that interested you in Trajectory, Pivotal Tracker, and Basecamp was the ability to manage tasks. How is that important in the clinical setting, and why isn’t it such a big feature in existing EMRs?

A.A task list (or scut list) is really at the heart of medical work. When caring for a patient there are myriad things that must be done, spanning routine clinical work such as ordering labs, more complex synchronous tasks such as communications with a family member or another doctor, and synthesizing complex clinical information to determine the next iteration of diagnosis, further testing and therapy for a given issue. And these tasks are generated by multiple members of a team and assigned to multiple members of a team. Given the stresses of clinical life, the performance pressure of having a patient in front of you, and little undistracted time to do work, the more complex tasks often get shifted to later, frequently never. Chaos and distraction increase the likelihood that these tasks are forgotten. But because the work we generate needs to get done, it felt natural to me that tracking, managing and thinking about tasks was of prime importance. In other words, a task list really represents the “work” part of clinical work. If we are going to take advantage of information and networking technologies, I can’t think of a better application of those technologies to a problem so horribly flawed by paper and verbal communication.

As interns, we each kept our own self-generated lists of things to do for each patient, our scut lists. An intern’s day consists of making and checking boxes. Easy ones first, asynchronous hard ones second, and the synchronous hard ones (meetings, calls) last. This method was inherently flawed because no one could check in on my progress, see if I needed help, or lighten my load. When I delegated a task, I had few ways to verify that it was done without interrupting the person that I asked for help. One stroke of brilliance had us photocopy our paper scut lists at the end of the “rounds” when all decisions were supposedly made. This allowed everyone to at least have the same starting conditions but was barely superior to individual lists. The closest successful implementation in the physical world was a large but portable white board in an Intensive Care Unit (ICU) visible to all, edited by all and serving as a single source of truth.

It is not entirely true that tasks are absent from current EMRs, it is just that the task feature, reflecting the culture of medicine that spawned it, fails to recognize that the doctor doesn’t do everything. Other EMRs I’ve used manage tasks like a message system, where disenfranchised phone/secretarial staff can transfer work, untriaged and unstarted to the appropriate physician. As a result, the task list/inbox feature of most EMRs is amongst the most dreaded, as physicians’ days end with a long string of unprocessed work. By contrast, because we went about building our team and culture differently, our task list is (and I can say this now that I am practicing) a method of team communication, delegation and accountability. It is by no means perfect, but leaps and bounds beyond what I have seen before.

There is a more fundamental issue here, which is the notion of “magic time” in medicine. “Magic time” is the time when doctors are supposed to do all of the things they do not in front of patients, like think about clinical issues, research clinical problems, make calls to family & specialists, read and write correspondence, etc. The problem is that there are always more patients with pressing concerns, and so there never is any time without patients in front of the doctor. As a result, we promise to call/write/think/research but often fail to do so, not out of malice, but because no opportunity exists to do so. With a task list we can begin to enumerate our days work, and do crazy things like assigning time to complete each task, and begin to actually recognize when we are overloaded, rather than waiting until the walls come crumbling down around us.

It is a joke that to make it through medical school you better have a good ToDo list. There are hundreds of forms, facts, meetings, certifications, etc. that must be met just to make it to doctor, almost none of which require the intelligence, creative thinking or compassion we hope make up the core of our physicians. I confess that I am a ToDo junkie, starting with beloved Palm Desktop and have now painstakingly migrated my ToDos to a platform that is iPhone, PC, iPad, and Mac OS friendly.

Q. In engineering nowadays, we tend to work off of a single backlog of tasks, with the highest priority task at the top, with the expectation that it will get done first. In a perfect world, how are medical tasks organized?

A. In a perfect world, each member of the team (patient included) would work of a common list and do the highest priority thing that they can do at any given time. Without sounding too naïve or presumptuous, I imagine there is more fungibility in who can do what on an engineering team. However most of good primary care is paperwork and nearly anyone can do it.

Having said that, there are two major problems with what I just said. The first is that priority means different things to different people—this is not unique to medicine. Threats to life and limb usually make it to the top. But for most of office-based medicine, there are murkier things. Important tasks like “eat more vegetables” or “remember to recheck the creatinine” often get put aside in favor of more urgent tasks. Paperwork forms, especially related to employment and always due today by 5pm, medication refills on the last day of the prescription and requests from regulatory bodies always bubble to the top of the list. Much of this is our fault as a clinical team—our process to handle such requests is woefully inadequate. Some would be alleviated by advanced planning on behalf of our patients (like if they had a todo list?). However, so many problems in medicine are not caused by either party in the room, but rather the result of decisions by regulators, lawyers & payors, who seem to assume all patients and doctors are either frauds or morons, loading up lives with meaningless paperwork designed (but unable) to mitigate such putative abuse.

The second problem with the ordering of tasks is that we have more than one patient at a time. Always. Is Ms. Jones’s high blood sugar more or less of a problem than Mr. Smith’s high cholesterol? Can such a distinction even be made? Rather than looking at importance, a near impossible task even with infinite resources, we again turn to urgency as our guide. Ms. Jones is coming in tomorrow, Mr. Smith next week. Therefore, let us take care of her sugar first.

This is a long way of saying that I don’t know what an ideal task list would look like, other than visible to everyone on the team, and dynamic. Which is how we designed it for ICIS.

Q. How do you deal with information overload?

A. Caffeine, long nights, frustration, delegation, more frustration, more caffeine, refusing to do certain things (looking at you insurance company forms) and finally, redesigning primary care from the ground up.

I actually found that in my private and professional life, the ability to get everything down on one list, spend a little time researching/describing the task problem when needed, and then assigning a time, place and resources to solving the problem has positive effects on both my psyche and my productivity. In other words, I deal with information overload with a really good Task list. (Notice a theme yet?)

Q. How do you balance what is the software’s responsibility and what is the doctor’s responsibility?

A. That’s easy—in front of the patient it is always the software’s fault. More seriously, something I have learned building software is to remember that it is just words. What I mean by that is that we must have a really good description of our problem and the solutions we would like to try before committing them to software. Not to be all waterfall, as it is rare that any solution we plan will actually be the right one, but rather that if I cannot describe my process to handle a problem without software, there is no way in hell I can create software to solve my problems.

Software is good at repeatable steps, never forgetting, and churning numbers. It can either recognize patterns, or help me recognize patterns (which is a huge part of clinical decision making, and probably all of human endeavor). It doesn’t need much sleep and can be in many places at once, but cannot feed or care for itself. It also, short of Skynet, cannot learn like a doctor can. Therefore it is the job of software to do what it is good at: automate steps that require no intervention, recognize patterns when my brain cannot, forget nothing, and help display things for me so I can use my honed clinical brain.

I tell all of my students and residents on day 1 that the most important part of being on a clinical team is that you have to do what you say you are going to do. Without confident delegation, a team will grind to a halt, and melt into a dysfunctional and wasteful group. The corollary is that to be a good team member, you must raise alarm as soon as you cannot do what you said you will. I expect the same from my software. If it claims that it will warn me about drug interactions, it better do it every time. If it is going to remind me that I didn’t do something that I set out to do, it better do it every time. If it said that my prescription was delivered, it better have been delivered. And if not, it better get my attention and tell me otherwise.

The time will come when software can do more and more of the physician work. What that really means is that we have gotten really good and describing the problems we face, and how we go about finding a solution. With better ideas come better words, better words leads to better software. Part of why I like being in the software world is that I think I have pretty good words for my processes.

Coming Friday, May 18: Part 2 of 2 (thoughts on gaming, operations, and billing)

The Value of Travelling Medicine

After many years of hard work and preparation, I finally have a chance to do what I have wanted since starting down the road of Medicine--innovate in Primary Care.  And a long road it has been!

Due to some unavoidable circumstances around physician staffing, my current work with Iora Health has offered me a chance to practice Primary care in our first open clinic, the Culinary Extra Clinic in Las Vegas, Nevada.  As some of you may know, I currently consider Boston my home, a vexing situation.  What we have worked out (we being my wife and my company), is for me to travel to and from Las Vegas weekly,  spending 3-4 days practicing primary care in our brand new and frankly amazing practice.  By Boston academic standards, this actually has me at full time (8 "sessions" per week, where one "session" is one half-day).  The road is long, the travel tiring, and the time away from my wife unbearable.  However, I have learned something about travelling to a single to location to work that my younger colleagues may wish to consider.

No matter where you do it, the practice of primary care can be consumptive.  Each patient has unique needs, often with much deferred self-care over the years, and in the presence of a supportive primary care system, the "work" to be done is staggering.  While my work as a physician is to recognize disease, help to prescribe and decide a path to health, and guide my patients as they walk--the real work lies with each individual to care for themselves and their family.  In any case, the days are long and the work both inspiring and tiring.  Now add to that the prospects of launching a brand new practice, as part of a larger, new company.  As you can imagine there is plenty to do. And I am grateful that I get to do it on the road.

Strange? Surely.  I had no idea that the travel would help.  It turns out that being stuck in a different city (and Las Vegas is certainly different from Boston), is incredibly beneficial when faced with the prospect of hard work.  While I miss my wife terribly, there is no signal other than hunger or fatigue that my day's work is done.  I have no plans, no friends calling me to go out, no obligations.  While this would be a sad existence in the long term, when faced with such monumental mountains of labor, I find it... comforting.

The ability to focus singly on one task is a gift in some ways.  It is certainly a privilege that I did not enjoy as a resident--always pulled in a million directions at work while simultaneously seeking the elusive and ill-defined "work-life balance."  But, if you can believe it, in Vegas there are no distractions.  I wake up, work out, work all day, eat dinner, work all night, sleep and repeat.  I am honing my craft and although the costs are high, I believe the rewards will be as well.

So some advice to my younger colleagues:  Get out there.  You either have been or are currently struggling in some type of race through medical school, residency, or the ranks of junior faculty.  You are trying to make a life for yourself in your chosen home town and all of its attendant benefits.  I implore those among you who can, to consider hitting the road for awhile.  Move some place different, commute far to work and really dive in to it.  The rewards will shock you.*

* I have only been doing this for 3 months, I will have more complete data in 3 more.

200 Pages on Diabetes, 1 paragraph on food supply

Sorry for the hiatus... you would think all of the plane travel to and from Las Vegas would give me plenty of time to write.  I do have some ideas that I have stored away and I hope to get them out in the next few hours to days.

Constant flying has afforded me one unique opportunity--the necessary need to disconnect from screens (iPhone/iPad/Mac Book Air) for just a few minutes when we are taking off.  Although the evidence around this policy is shoddy at best, I have learned to pack real live printed materials to entertain me during the endless waiting between sitting down and plugging back in.  Most often, journals such as Health Affairs or the New England Journal of Medicine fill this time.

The January issue of Health Affairs, a well-respected, in-depth monthly look at health policy research and proposal, focused on Diabetes as the theme for the issue.  As usual, a collection of well-thought out and well-intentioned articles fill the pages of this journal, examining the effects of existing laws and programs, and proposing new, population wide strategies to combat disease and improve health.  Prominent among the articles were suggestions of financial incentives (or taxes) on certain individual behaviors to promote a lifestyle that would avoid diabetes.  The usual suggestions of taxing sodas to save the world were laid forth. What struck me the most about this issue was not what was suggested, but what was ignored--the food supply.

In the typical policy attempt to draft smarter and better regulations to more adeptly mold human behavior to fit some vision or another, new laws and new restrictions are always proposed.  In an almost comically predictable fashion, there is almost zero evaluation of previous programs or policies with the same intended consequences, and even more sparingly, evaluation of seemingly unrelated laws with disastrous consequences.  In this case, in over 200 pages on proposals for policy changes on diabetes, I could find only 1 paragraph discussing the laws that govern our food supply.

One paragraph.

While Diabetes is a multifactorial condition (code for we have some great ideas but no clear mechanism of disease), it is indisputably linked to food consumption.  There is a stark correlation between changes in the American (and subsequently the world) food supply towards corn and corn-derived food sweeteners and a shocking increase in diabetes.  (Again, correlation, not causation).  So why go after corn?  It turns out that the reason for the shift away from sugar to corn is the result of, you guessed it, former public policy decision in the United States.  I am not talking about health regulations, but about farm subsidies.

It is US Agricultural policy that determines that corn is cheap and plentiful, and its derivatives fill our groceries stores and stomachs.  Does this cause diabetes? I do not have convincing evidence, but enough suspicion to voluntarily choose to avoid the stuff whenever possible and advice friends, family and patients to do the same. To be honest, ever since we covered how well the body regulates glucose metabolism vs. fructose metabolism, I have been convinced that this stuff is at least undesirable.

Farming politics and Biochemistry aside, I always find it frustrating that the solution to the unintended consequences of one law is to prescribe more laws.  As a physician I am guilty of the same, often using one medicine to counteract the effects of another (breaking Solomon's Law of Pharmacology).  Not to excuse my own behavior, but there are very few drugs out there and I have no ability to modify any of them.  Stark contrast to our political and regulatory system, which as the ability to modify and improve itself retroactively but chooses to do so only through new prescriptions.

While I applaud my colleagues efforts at applying their skill set to what is a broad and complex problem, I would caution all current and future policy makers to consider the effects of what your predecessors have done before jumping into the dance yourself.  Perhaps the next time Health Affairs covers diabetes, they can look back at undoing causes instead of proposing to limit individual freedoms to make up for errors at the policy level.

Is there a doctor on the plane? Better check his ID.

So here I sit, delayed, en route again to Las Vegas.  On my last trip out there I was awakened by the call that all medical students secretly crave, and all physicians loathe... "Is there a doctor on the plane?"

Grabbing my shoes in my right hand and bounding towards the front I arrived to find out what was going on.  It turns out a youngish gentleman had falled to one knee and potentially passed out while attempting to go to the bathroom.  By the time I arrived he was awake and seated and looked only a little worse for the wear.  A quick conversation with him and his friend indicated the likely cause-- an 80 degree airplane (couldn't they open a window?) and an afternoon of drinking had left him fairly dry, and he suffered a bit of the old vasovagal syncope.  With the assistance of another passenger, a nurse, I was able to barely obtain vitals with the loud plane and the small stethoscope.

The three flight attendants were variably helpful, one accurately reading the situation and supplying the water & juice, ice packs and vomit bag that I requested.  A second was insistent that oxygen would help, and so I obliged.  But the third...  the third one was there to do the paperwork.  It looks like healthcare is the same everywhere.  Thankfully she wrote most of what I was saying down so I didn't have to write a visit note myself (As though I were submitting a bill).

Things got very interesting when I asked what was in the medkit. I observed a small back pack size kit that was "very well-equipped" but no one could accurate describe the contents.  I asked if we could open the kit so I could familiarize myself with the tools.  Not that our patient needed any more services than we were currently providing, but I have learned to know my tools and plan ahead.  I was told repeatedly that unless I knew what I wanted out of the kit (impossible as I did not know the contents), that they did not want to open it because they would have to call it in and fill out yet more paperwork.  Understandable I guess, but who decided to set the paperwork bar so damn high?  Had the gentleman been sicker am I really supposed to negotiate with someone at 30,000 feet about how much paperwork they have to do?

Fortunately our patient did well and no drastic decisions were required.  At the conclusion of the who situation I received a brief thanks from the staff, and then it happened.  "Um, Doctor... can we have a copy of your medical license?"

AFTER?!?!  Barely a thank you, not to mention the free drink or upgrade my family or friends insist I rightfully deserve, (I am not so naive...), but after I have rendered a service and made a medical decision, that is your chief concern, to make sure I am not faking?

I am sure the on board medical emergency policy was decided upon by very intelligent folks with a great background, not at 30,000 feet, but from an airline that prides itself on service (and usually delivers), I felt that the entire situation was odd a best and stinking of litigation fear at worst.

I am flying again tonight, and if called I will be there.  But I really hope I can sleep on my now delayed flight to Las Vegas.

Latest from the SGIM Forum: “It’s not What You Earn but What You Keep That Counts"

My latest publication in the Society of General Internal Medicine Forum, about the mystery of doctors being both overpaid and underpaid.  I'd like to thank my mother-in-law, Iris Stern, for sending me the article that was the inspiration for this piece.

Cost of Care Essay Winners

The folks at Costs of Care have started posting the winning essay.  The first is by Renee Lux, a patient who underwent a CT scan "just in case" and found herself uninsurable!  It is a chilling description of just how distanced the clinical and the underwriting have become in modern health insurance.

Speaking of ICUs... Check out the Intensive Code Unit

Check out the Intensive Code Unit, the ongoing masterpiece of our technical team at Iora Health.

My first panel

Last night I had the honor of serving on my very first panel on Primary Care Innovation at Harvard Medical School.  Arranged by the Center for Primary Care @ HMS and Primary Care Progress, I had the pleasure of sitting with luminaries Soma Stout, Asaf Bitton and David Judge and share our work in Primary Care innovation with a group of enthusiastic medical students.  There apparently was a video, and I proposed to the others that we take our show on the road.

One of the questions that came up was how to square ideologic differences between each of us with our work in primary care.  We were asked which was more important, maximum equity, maximum efficiency, etc.  I think we all chuckled as we recognize that right now all we have is maximum waste!  I actual look forward to a future when all of us working hard to reinvent primary care and all health care can bicker as old men and women about the exact ideal direction to go.  Until then, we keep solving one problem at a time, moving forward.

To the students out there who are interested, we at Iora Health are looking for a medical student to join us for (at least) the summer, and perhaps a resident intermittently throughout the year to help with some of our exciting work.  If you are interested, please e-mail me.

Cost of Care Essay

It has been a wild ride since I entered the Costs of Care Essay competition.  The Boston Globe reported on it here (with a nice promo for the Schutzblog).  Here is the essay in full:

“$1400 a day!”

Cost of Care Essay Contest Submission

Andrew Schutzbank MD, MPH

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension.  So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open.  Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension.  Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours.  Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision.  As you can imagine, this drug was mighty expensive.  We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs.  Once stabilized, our first challenge was to ensure that she continued on the treprostinil.  It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress.  Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab.  But her progress was stalled for one simple reason: treprostinil. 

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her.  As it turns out, treprostinil costs $1400 per day.  $1400.  Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state.  But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized.  Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment.  A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home.  Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil).  But we are doctors, not financial engineers.  We work in the world of medicines and were unable to orchestrate such an unusual arrangement.  So we did the only thing we know how to do.  We stopped the expensive medicine.

This was not a financial decision.  Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines.  Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense.   We monitored her closely during the transition and she quickly improved!  She was able to move around more and started on recovery.  She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one.  But ironically, we would not have considered it if were not for the cost factor of the medicine.  Peggy would have gone on for some time on an expensive medicine that was not helping her.  At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied.  The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day.  Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time. 

Shameless self-promotion, round 2

Bringing home the bacon!