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”.

Continue reading

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

workspaces that work

What helps you be healthy, happy, and productive when you need to be in the zone— whether that’s at your job, in your creative workspace, or somewhere else? Many of us spend a ton of time working at our desks— almost as much overall as we spend in bed, sometimes. And as with sleep, work goes better if we get the environment right.

For me, a big piece is being able to move around. I fidget, shift position, stand, sit, stretch, cross/uncross my legs, squat, sit on the floor, sit in half-lotus on my office chair. . . as I’ve heard Kelly Starrett Say, the best position is the next position. While I’m all about the ergonomics experts who will adjust your mouse and your monitor and whatnot, I think the best solution is generally to avoid spending too much time in one position to begin with. Variations on office furniture that help this? Sitting on something like a ball instead of a chair, a standing/adjustable desk, a treadmill/bike desk, stools/footrests, and my personal favorite— the headset, so you can take calls while moving around.

What else? Continue reading

yellow safety first sign

How to keep yourself safe

  1. Stop worrying so much about being safe.

Life isn’t safe. Excellence isn’t safe. Innovation isn’t safe. Fun isn’t safe. And truly, what’s “safe” for the short-term is often not so over time. Staying at home and watching TV is safe, but it boredom and inactivity are perilous in their own ways. Staying in a job that you don’t love is safe, but burnout and lack of interest are real dangers.

It’s OK to get dirty, to get a few bruises, to get lost. These are often some of our most memorable and transformative experiences. Sure, there are limits. Common sense things— wear a helmet, tell someone where you’re going. But for pete’s sake, go! When I go to my krav maga class, I don’t take hard hits to the head, but I get hit. I get bruises. This is a good thing— it lets me know that I don’t need to shut down and freak out if I get a little roughed up. Because in life, you WILL get roughed up, even if you’re  careful. Continue reading

It’s the iliopsoas, stupid!

What do low back pain, knee problems, poor pelvic alignment, hip popping, and weak glute muscles have in common? Besides the fact that all of these things suck and they are common complaints in my clinic. . . read on.

illustration of iliopsoas musclesThe iliopsoas (the p is silent) muscles run from the lumbar vertebrae (lower back) and interior of the ilium (hip/pelvis bones) to the inside of the femur (thigh bone). There are actually two muscles that make up this group: the psoas major (origin at T12-L5 vertebrae) and the iliacus (origin at iliac fossa of ilium). They are generally considered together, and they generally act together and insert together at the lesser trochanter of the femur. Phew. Ok. Why should you care about these little dudes?

Mirror muscles, they are not. Because they’re located deep to other structures, it’s not easy to see and feel them, so many people aren’t even aware that they’re there until something goes awry. But they are critically important to function and performance. The iliopsoas mucles are major hip flexors, pulling the thigh up to the abdomen, and stabilizers of the trunk and pelvis. They get major action with movements like running and cycling, or the constant external rotation of things like ballet, but they can also get weak and tight from sitting in a chair for long periods of time. Think about where those muscles go and what your position is doing to them. Sitting followed by hard training? That sounds like a perfect storm. No wonder they are often troublemakers!

What happens when things aren’t right in iliopsoas land? Sometimes it’s hip-specific problems like:

  • snapping hip syndrome, thought to be related to iliopsoas tendinitis or tendinosis
  • Iliopsoas bursitis, painful inflammation of the cuishioning fluid sacs
  • iliopsoas syndrome- pain and stiffness that can travel to the abdomen, butt, groin, lower back, hip, and thigh

But the trouble can also be more insidious. Continue reading