Book Club: An American Sickness

The U.S. healthcare system is a hot mess. Even people who know things are convoluted and expensive might not realize the extent: we pay far more for just about all aspects of healthcare here than anywhere else, and our outcomes are worse pretty much across the board (see this article from the Commonwealth Fund for details).  As tempting as it is to implicitly trust that you’ll get the best care in the world right here, the facts would suggest otherwise. Every other major developed economny in the world as some form of universal access. So why do Americans cling to the idea that our healthcare market is somehow sacred, and that a market-based approach is the answer? I’ve talked about why healthcare is not just another commodity before, but it’s still true.

Elisabeth Rosenthal, a physician turned journalist who has worked for the NYT and Kaiser Health News, wrote a book last year. In it, she exposes a lot of the causes and effects of the major malfunctions in our healthcare system. Much of this is illuminating— examples about hospital conglomerates and pharmaceutical pricing are spot-on. But what seems to lack punch is the explanation for why this upside-down, losing system persists. When healthcare is treated like every other business, greed drives, incentives are bonkers, and lobbyists shape policy. When healthcare is considered as a public service, things are different. But once powerful people are making obscene amounts of money, it’s nigh impossible to unring that bell. Are there market failures? Big time. Can the people affected muster enough influence to combat the big-money lobbying of professions and industry that have become accustomed to fat-cat money? Fat chance.

Aother quibble: Rosenthal is mercelessly physician-centric. She doesn’t consider the unique added value of team-based healthcare or other professional expertise, choosing instead to lump unique professions like NPs and PAs together as “extenders”. Barf. Dr. Rosenthal, I wish you’d take a broader view of health.

That said, give it a read. It’s interesting/depressing. And you might pick up some useful tips for your nex hospital visit, knock on wood.

What we talk about when we talk about research findings in the news

What happens when journalists report the findings of a scientific study to the general public? Often, the findings are stated out of context, broadly interpreted, and stripped of the nuance and uncertainty that characterize much of scientific research.  Should this scare us back from publicizing findings to a wider audience than you might typically find in a scientific journal? Or is publicity critical to uptake?

What is our responsibility as scientists to communicate our findings, not only through dedicated dissemination and implementation planning, but also through the popular press?

Here’s a recent example. JAMA published the findings of a study by Mandager et al.  on the association of cardiorespiratory fitness (CRF) with long-term mortality. CRF was measured by exercise treadmill testing in a sample of over 120,000 patients who were having this test done anyway as part of their care (that means these people were mostly being evaluated for symptoms potentially related to cardiovascular disease). The investigators quantified CRF as peak estimated METs. They separated by sex and age to calculate percentiles and then stratified CRF based on those percentiles. They used public and hospital records to determine mortality. Median follow-up was 8.4 years. The investigators concluded that CRF was significantly inversely associated with all-cause mortality (i.e., the fitter you are, the less likely you are to die). They went on to state that low CRF was as risky as or riskier than diabetes, CAD, or smoking. They also noted, importantly, that “there does not appear to be an upper limit of aerobic fitness above which a survival benefit is no longer observed”, but “there continues to be uncertainty regarding the relative benefit or potential risk of extreme levels of exercise and fitness”. They go on to offer several other sensible caveats, including that the study population may not be representative of the general population, and there are potentially significant unmeasured factors in this retrospective study. All things considered, though, this seems to represent very good news: a modifiable factor is strongly associated with increased longevity in a large sample with a long follow-up.  Bravo!

So how did this get reported in the popular press? Gizmodo’s headline reads “No Such Thing As Too Much Exercise, Study Finds”.

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high score screen

In praise of being a generalist

There’s something undeniably alluring about being highly accomplished at something. Being the best. Being at the top of your field, your game, your performance. But there’s an opportunity cost to this kind of excellence— the time and focus you dedicate to one thing, you are not dedicating to anything else. Can single-minded focus actually undermine your effectiveness? It depends on what you are doing. . .

Let’s think about this through the lens of running for a moment. We are not all 100m sprinters, even though that’s impressive, and you can win cash and medals and huge endorsements and titles like “the fastest man in the world.” But is Usain Bolt, impressive as he is, better at everything than you are? Is he a better human than you are? His speed is truly amazing, but it’s just speed. This is why obstacle course races are cool— you have to be fast, but you also have to be tough, have power, have strength, have skills. Even the crossfit games (as mixed as my feelings are about crossfit) are a good example of testing a broad set of competencies rather than a narrow one.

I’ve been thinking about this a lot because I am not, shall we say, a highly focused individual. I am curious, a bricoleur, a person who loves to say yes and follow side trails. My grandmother once wrote a poem about my twin sister and me, where she was the arrow and I was the hummingbird. She was a smart lady, my grandmother.  Continue reading

The Badass Female Project: the Woman who hates Men who hate Women

I’m starting with Lisbeth Salander because she’s the one who got me thinking about this. I liked the idea of working more with female creators as well as female characters, and I still do, but I love Lisbeth so much that I can’t leave her waiting. It took me years to start reading this series, because it seemed like a fad, like a throw-away thriller. . . but no, no, no. They’re  action-packed, yes, but also smart, creative, and thought-provoking. (There are movies, too— a Swedish triology, and an American version. They’re all pretty good, but read the books first. I’m just a book person, OK?).

First, a little background (but no spoilers): Lisbeth Salander is the protagonist of Swedish writer Stieg Larsson’s “Millenium” series, the first and most well-known of which is called The Girl With the Dragon Tattoo in English. The translation of the original title, however, is Men Who Hate Women. They should have kept it, because it’s the heart of what makes Lisbeth a badass. Not her boxing, hacking skills, tattoos, or motorbike (but those are all pretty dope). Lisbeth Salander has a solid internal moral code, and she is not cowed by anyone or anything. She will not excuse men who hate women, and she has plenty of material to work with.

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What happens when a plant-loving scientist watches What the Health

I’m not a diet absolutist or a purist, but if I had to join a diet camp and stay there, it would be with the vegans, and specifically the whole-foods, plant-based vegans. My experience and common sense tell me that this is a good way to eat. There’s some evidence that it’s healthy. There’s a lot of evidence that it’s economically and environmentally sound. Mostly vegetables, fruits, whole grains, nuts and seeds, all that good stuff. I’m for it. IMG_1435

So this week, I watched the much-discussed What the Health, since when my partner’s out of town, all I do is watch documentaries about fitness and stuff. As a person who is personally and professionally invested in health, I wanted to like it. But alas, I was thoroughly disappointed, and even a little pissed off.  Yes, I’m late to the party. But whatever. The thing is, I think the overall message is probably right– processed meat is bad for you, industrial production of  animal foods creates major health hazards, animal agriculture is an ethical and environmental abomination, and major health advocacy groups take money from corporations that promote unhealthy products, thereby creating a colossal conflict of interest. So why package this message in a bunch of evangelism, cheap tricks, and scientific misrepresentation? It’s bad for the message.

whatthehealth

indeed.

Let’s take a moment to discuss crimes against science: no credible scientific paper would ever say something like “this definitely shows beyond the shadow of a doubt that a always causes b no matter what, and this is 100% true beyond the shadow of a doubt.” Science doesn’t work that way. Evidence accumulates– with nuanced approaches and varied findings, and over time, it may start to become clear what’s likely going on. Scientists study the studies and look at patterns and trends. They create meta-analyses and systematic reviews. They build a body of credible evidence. They don’t pull a handful of individual studies out and ask why they haven’t been made into policy.

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On Alignment

What do you think of when you hear the word alignment? The wheels on your car? Your body position in a yoga pose? I bet it’s not online education. . . but hear me out.

Because I believe breakthroughs come from cross-pollination among disciplines, I’m going to borrow this concept from Quality Matters— which is a system for evaluating the quality of online courses. In this context, alignment refers to the relationships among course objectives, unit or module objectives, instructional materials, learning activities, and assessments. Are the outcomes measurable and appropriate, at both levels? Are the course components aligned with those outcomes? This sounds basic, but it can be surprisingly challenging to achieve. Mapping out these connections can be difficult– and enlightening. I’ve done it as both a course instructor and a peer reviewer for other courses, and found it enormously valuable.

So let’s distill this idea down to the basic components: set high-level goals, set smaller goals to support the big goals, and choose actions and assessments that align with those goals.

Where else can we use this simple structure to improve things?

  • Clinical management. The patient’s “big-picture” goals are surprisingly frequently absent from the conversation. But patient-centered care demands identifying goals for health and for life. A care plan that doesn’t include an assessment of goals is in peril before it even gets off the ground. And I don’t mean goals like “get A1C less than 7%”. I mean goals like “extend my healthy lifespan so that I can travel in retirement”. That might be a radical shift and it might alter management. Or it might mean the same basic management plan is perceived very differently by the patient. I’ve written about the concept of concordance in healthcare before– it’s similar. Aligning our plans to treat, follow-up, and assess our patients with our shared goals, both long-term and more immediate, is crucial to effective care.
  • Career trajectories. I recently wrote about the challenges of focus in an academic/clinical career.  What if, instead of a single-minded focus on a narrow area, each opportunity is considered in terms of alignment with “big-picture” goals? This approach allows for more bricolage (which, BTW, can make work relevant and grounded), more cross-pollination, more serendipity, more diversity– without falling into a scattered mess. I have a couple of broad interest areas and goals, and I find that rather than continue to narrow into extreme sub-specialization, I prefer to exist as a practicing member of the communities I’m a part of, and participate in projects that align with those areas.
  • Self development. This is what tools like the Passion Planner promote– making big goals, identifying smaller pieces of those goals, and taking steps to move towards them. The act of identifying goals, and identifying small steps, is enormously powerful in making progress. It takes deliberate thought and reflection, but the outcomes of small actions over time that are all aligned with a goal can be mind-blowing.

So there you go. Take a simple principle, and see how powerful it can be in different contexts. Think about how Atul Gawande used a checklist strategy from aviation to improve surgery, and think about what big ideas might disrupt your regular practices.