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.

From hard targets to risk models: Who are we helping?

There’s something appealing about a threshold-based approach to treatment: if your cholesterol is over 200, it’s high. If your blood pressure is over 140, it’s high. If you A1C is over 7, it’s high. It’s clean, easy to understand and easy to communicate. But is it helping to improve meaningful outcomes, and is it doing so equitably? Does 140 for me create the same problem as 140 for you? Is 141 worlds away from 139? These aren’t easy questions to answer. It complicates the already complicated conversations around taking medications for prevention.

We’re starting to see evidence across different conditions that risk-based approaches to treatment, i.e. those that treat based on aggregation of multiple risk factors into a predicted risk of some adverse outcome, might be better. The first major test-case for this was lipid guidelines, but recommendations for other conditions are starting to change too:

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dealing with death.


In Tucson each November, there is an event called the All Souls’ Procession. It’s a relative of the Mexican holiday Dia de los Muertos, but it’s a distinct and unique experience. People come together and walk through the city with floats, puppets, photos, banners. They dance, chant, drum. They paint their faces and wear costumes. There’s a giant urn. There’s a celbratory aspect, but also a solemnity. There’s a shared sense of loss and solidarity. It’s moving and remarkable.

In most of America, anxiety around death is rampant. There are huge silicon valley projects dedicated to promoting longevity. We talk about “not giving up” and “fighting.” We put 85-year-old people with failing organs on ventilators and tube feeds at great expense, both in finances and in human suffering. We use euphamisms like “passed on”.  We generally don’t think and talk about the fact that death is a presupposition of life— the thing that, by oppostion, defines it, and the place that it ends. Life and death are in this way inseperable. It’s a strain on our society, I think, to stick our fingers in our ears and ignore this.

Of course there are people who resist this tendancy to avoid thee idea death. Continue reading

Why patients clash with doctors

I’ve seen several loved ones frustrated by interactions with the medical system lately, and after my initial knee-jerk reaction of “how dare they mess with one of my people” and “we have a shitty system, and we probably always will,” I got to thinking more about it. Why do people who are seeking help from a medical professional so often walk away feeling demoralized and disrespected, in addition to whatever problem brought them in in the first place?

Generally speaking, people choose careers in medicine because they want to connect with and help others. Medical school is grueling, and expensive, and people generally don’t do it if they don’t have some inclination towards service of others. Likewise, people seek out care from physicians because they want to feel better. Something isn’t right, and physicians are there to tell you what it is and how to fix it. They’re not stupid or lazy, just sick. By and large, this all lines up. So where do things go wrong? Let’s check out this handy chart:

Medical Visit


A few thoughts:

  • Doctors expect to be able to fix any “real” problem. This is how they’re trained— “true disease declares itself” is a common mindset.
  • Patients expect doctors to be able to fix any problem. All problems are “real.”
  • Some problems are well defined and understood within the structure of allopathic medicine.
  • Some problems are not well defined and understood within the structure of allopathic medicine. But they are not less real!
  • When patients present to doctors with problems from column b, things can go bad. Patients feel like they are not being listened to, taken seriously, or understood. Doctors feel like patients are being non-compliant, have unreasonable expectations, or are hypochondriacs. Everyone thinks everyone else is a jerk.

So what’s the root of this mess?

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why how we pay for healthcare actually matters

I have a patient in my practice, Francisco, who showed up to the walk-in clinic one day looking awful. His wife had driven him— insisted, he told me.  Fransisco was an always-upbeat guy who I had treated over the years for the major and chronic (uncontrolled diabetes) to the minor and self-limited (smashed thumb). He’s an auto mechanic who supports a big extended family. He’s hard-working. He always says thank you. He’s downright jolly, even when life gives him lemons. But this day, he was struggling to remain cheerful. He had nearly fallen in the shower, he told me, and felt dizzy, weak and sweaty. He had a headache, or sometimes more of an upper back/shoulder pain. It wasn’t going away.

I had a sinking feeling as I asked the medical assistant to check his blood sugar and vital signs. Francisco’s medical history put him at high risk for a number of life-threatening problems— things like a heart attack, or a diabetic coma. His blood sugar was normal. Damn, I thought, that would have been relatively easy to fix. His heart rate was too high. His oxygen level was too low.

He needed an EKG. He needed some blood tests. A full-service primary care clinic would have those things. My free mobile clinic did not. Even if I had more resources at hand, though, he needed to go to the emergency room where there were nurses and cardiologists and resources and machines. They would evaluate him, stabilize him, and treat him. They have to— it’s the law. But then, I knew, they would bill him. He might quality for emergency Medicaid, but given his and his wife’s modest incomes and their family’s complicated immigration status, it wasn’t clear whether he would. But when you need medical care right now, you’ll figure out how to pay for it later. You want to live right now.

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Why healthcare isn’t just another commodity

If you are a person with a lot of choices, with a job that offers health insurance, with a social security number and a safe place to sleep and knowledge of where your next meal is coming from, I can see how you might think a market-based healthcare model is a good idea. You might be annoyed at your doctor, or the confusing bill, or the insurance company, but when something shitty happens to you, you aren’t really worried that you’re not going to be able to get help.

And I know that a lot of people in this position of privilege think (wrongly) that these basic pieces of a stable, comfortable life are accessible to anyone willing to work hard enough to get them. That everyone has basically good options but some people take advantage while others are lazy, entitled, or whatever other excuse might bubble up. This is infuriating because it is so, so wrong. It’s like that old adage of being born on third base and thinking you hit a triple. A lot of folks were born without even a bat to swing. Those folks are just as human as you are.

So imagine you are 58 years old, and your daughter just had a baby. Continue reading