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Dr. Darrell White's Personal Blog

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Archive for September, 2016

Population Health v10.0

There is a certain arrogance in the academy, that vaunted group of professors who opine righteously from afar about pretty much anything they study. Add to that the well-known arrogance of youth with its inherent disregard for any and all history which transpired before the youthful reached the age of cognition and you have either a toxic combination of ignorance and impetuosity, or simply a laughably vacuous collection of paper thin pontification. Such is the case with a series of statements quoted yesterday morning from a lecture given by a young academic physician on the state of population or public health in America. He posits that there is a new movement toward moving healthcare from inpatient to outpatient. There is an equally new and heretofore unseen effort to make people healthy rather than treat them when they are not. This young doctor is calling his observations Population Health v1.0.

I’m calling it Bullshit.

The lecture in question was being live-Tweeted, but that is probably the only thing about the subject matter that can reasonably be v1.anything. Instantly available dissemination of medical information to a general audience is a truly new phenomenon. With it comes the danger of the wider audience simply accepting the information since it comes from an “expert”. However, along with the relatively naive broader audience we thankfully have a small subset that is either a) informed enough on the topic to offer a “con” opinion, or b) simply old enough to remember that there is a deep and meaningful history that predates what the young expert is proposing as new. Count me as able to check c) both of the above.

Population Health is simply a better term for what historically has been known as Public Health. While Public Health typically connotes some sort of governmental involvement, Population Health is a more inclusive, more powerful concept because it includes not only government programs but also private initiatives of all kinds. Public Health typically equates to top-down implementation of global governmental policy, whereas Population Health covers everything from large for-profit publicly traded companies to the tiniest solo-practice pediatrician. In fairness to the speaker (and in a kind of peace offering for what is to come) I do think his choice of a label is spot on. The rest of his thesis and its development? Not so much.

There is literally nothing new in the entire exposition. How can you call anything v1.0, the first iteration of something that is truly new, if everything that is used as an example is simply today’s version of yesterday’s news. Let’s start with his primary assertion, that there is a new move afoot in which healthcare is only now being provided in the outpatient, rather than the inpatient, setting. This can’t be a doctor who is taking care of any patients in the real world. It is long been the exception rather than the rule that a majority of surgeries take place in an outpatient setting. Heck, 99.9% of eye surgeries have occurred in this setting since the 1980′s. So, too, for invasive testing like colonoscopy, bronchoscopy and cardiac catheterizations of all kinds. It would be much more accurate to state that we are in the end game phase of this transition, v10.0 if you will. For crying out loud, this is such a mature part of the evolution of healthcare in America that any essence of patient-centered care that would require an admission to a hospital is dismissed outright, one more nail in the coffin of that now meaningless label.

How about the assertion that we are only now engaging in a concerted effort to improve the health of our population as opposed to simply treating various maladies? This one kills me. Really? All of a sudden the entire healthcare/government/industry axis is only now finally seeking to improve the general health of our people by preventing illness? Now, in 2016, we have population health v1.0?! That’s laughable. If our young scholar is anything like yours truly, the last stop he made before making his way to the lectern was the loo. HeLOOOoh. Indoor plumbing anyone? You can make a sincere argument that v1.0 of population health efforts occurred a hundred hears ago with the introduction of the kitchen sink and the toilet.

If we confine our discussion to matters more purely medical any reasonable view must acknowledge the tremendous life-saving effect of mass vaccinations for childhood illnesses. Smallpox, polio, and measles each killed hundreds of thousands every year before the advent of widespread vaccination programs. Even efforts which we would now condemn like the sequestration of TB patients in sanitariums must be considered a type of population health program. Despite our modern day fetish with privacy issues, the near elimination of syphilis  in the Western world through mandatory case reporting and contact notification cannot be forgotten or ignored.

When we talk of Population Health in this day and age we are typically talking about mitigating the effects of modern society. Indeed, in cases such as nutrition, we are actually talking about undoing the adverse effects of prior Population Health efforts. The U.S. government either simply got it wrong, or was led awry by a cynical effort by food producers who surreptitiously funded self-serving research. No matter. We are now in possession of a sedentary, overweight population susceptible to once less common diseases that now run rampant. There is little argument that the healthcare community should engage in the effort to keep people healthy as well as treat them when they are not. The notion that this is something truly new is a fanciful notion bred of what must be purposeful historical ignorance.

So, Population Health v1.0? Hardly. A process that arguably began with the invention of the flush toilet cannot be labeled new, no matter how good this makes a speaker, a system sound, or a concept sound. Those who fail to study history may be doomed to repeat it, though in this case there really is no need to do so. Acknowledge the past, make a sincere effort to place your idea in its appropriate slot in that history, and then make a case for your proposal. Have a little humility. There’s nothing wrong with being v10.0. Especially if it works.

 

 

 

 

 

A Quick Thought on Measuring Health

Thoughts I’m thinking while following a vacuous, arrogant, self-congratulatory, and epically ignorant of history exposition on public health over on my Twitter feed…

It seems as if the entire world is in search for the magic metric that will allow us to measure, and then manipulate, health. Frankly, I’m stuck in my own search for a metric that combines Fitness (as defined by Greg Glassman), traditional western medical measurements (serum lipids, BP, waist/hip, etc.), and emotional well-being. Wouldn’t it be something if all you needed to do was accurately measure your pulse? What if your pulse, one of the easiest things to measure there is–all you need is a second hand and the ability to count–could predict everything about your health with the exception of bad karma stuff like depression or cancer? More than that, what if you then could be told what your pulse pattern needed to be and how to effect that?

In Scandinavia a long-term study was done on men looking at specific variations in pulse. Resting, peak, speed to peak, speed to recovery and the like were all recorded, and cardiac events/deaths were then analyzed against the data. The result of this research was a proprietary algorithm, the PAI (owned by a company called Mio Global) that posits a direct association between specific pulse patterns and longevity. Indeed, they boldly state that a PAI of 100 equals up to 10 additional years of life, presumably free of decrepitude (reflecting my CrossFit-affected view of life). Imagine for a moment how earth-shaking this would be. Having an actionable metric for health, especially one that is as easily accessible as your pulse, would allow us to critically evaluate a majority of health interventions available.

Nothing is that simple of course, but it is quite easy to envision a pyramid of health, not unlike our CrossFit pyramid of fitness, with a base that consists of your PAI. Layer on whatever you please, but the smart money is that something that looks an awful lot like CrossFit’s 100 words of fitness will be in there somewhere.

I’m off to take my pulse and then do a WOD.

 

Sunday musings (The Purge)…

Sunday musings…

1) Anniversary. It literally just occurred to me that Clan bingo moved to Cleveland 25 years ago this month.

2) Birthday. The Man Cub turned 1 yesterday. Massive party complete with the latest trend, the “smash cake.”

Still pulling icing out of his nose, and his ears, and…

3) Pro health. Outside mag has an interesting article on the pursuit of ultimate physical performance. Aside from the obligatory dig at CrossFit (“injury factory”), the author’s visit to the Exos group at the StubHub Center (of all places) was illuminating. My reading of the article is that upwards of 90% of what is happening at places like this is precisely what has been going on in the CF competition world for some 3+ years now. Dynamic W/U, an emphasis on mobility, programmed recovery, tightly managed nutrition. There is much more use of supplements as a primary element than traditional CF; I’m not sure if that is necessary for the masses, those of us who don’t compete. The author saw a real, measureable improvement in not only fitness but also applied fitness.

The mic drop, however obvious, came at the end of the article when the author described his slow, inevitable slide back to average. Why? Easy. While he was “in residence” at Ethos the entirety of each day was filled with nothing other than being a better athlete. Back home it was easy to revert to old habits. A missed workout here; too rushed to work on flexibility there. And beer. Beer is a problem.

Being at your peak physical capacity is a full time endeavor for the pro athlete. That, as much as anything, is what separates you and me from them.

4) Purge. In a couple of days we will be one step closer to completing “The Purge”. No, no…not THAT purge. I’m talking about completing the purge of all of the stuff that filled up our larger home with all of its modern storage spaces. Our new home, a tiny 1947 two-bedroom cottage, is 50% to the inch the size of our old home, but it has only 1/3 as much storage. Our purge has partially furnished at least 3 other homes, and the upcoming delivery to “Lovely Daughter” adds another home to the list.

Clothes, art, tchokes…you name it. We’ve been liberated from our stuff.

Have you ever seen George Carlin’s classic riff on “Stuff”? Truly funny stuff (Huh? Huh?), and easily available on YouTube. An entire cottage industry has grown up around the purging of stuff. That’s kinda funny, actually. The concept that you need someone to come in and tell you how to get rid of your stuff. In addition to a few minutes of belly laughs, Carlin gives you the place to look for low-hanging fruit: other people’s stuff! Set a timer, and if them others don’t pick up their stuff, off it goes.

The harder part, if it’s really all that hard at all, is when you are down to the stuff you think you might need someday. You know, like that really interesting, sure to be useful gadget you just had to buy at Sur La Table 10 years ago that’s still in its original packaging. Or those holiday dishes you’ve forgotten to use every Christmas since you got married 25 years ago. Stuff like that. When you literally don’t have a place to put ‘em, this category becomes not at all different from other people’s stuff: if you never used it, it was never really yours, right?

Before I get too self-congratulatory and get injured by patting myself on the back, I should point out that we DO have an attic, and also a tiny little vestigial cellar. Both are filled with unpacked, lovingly examined, and re-packed memories. Sure, I could digitize the photos and upload them to the Cloud. The 55 year old “Teddy Monkey” that hasn’t been cuddled for 2 decades would certainly fit better in an album than a box. It’s here where the line is drawn in our home, that place where “stuff” intersects with memories. Maybe I’m too old school, or perhaps just plain old, but the memories and the things that trigger the memories are safe from the Purge.

The whole exercise has been a helpful and useful one in my never-ending journey on the “want vs. need” highway. Stuff? Firmly on the “want” side of that equation. Every day in our cottage, more joy from less. Letting go of the stuff has also brought me closer to cherished memories, which in turn is bringing me closer to cherished people. Funny, eh? The less room I have for stuff, the more room I come to have for the people who helped me make the memories I’ve been saving. I’m off at the moment to round up a couple of those people, hopefully to create a few more of those memories.

After all, the size of your heart and soul need not be bounded by the kinds of walls that surround your stuff. There can always be room for your memories and the people who made them with you.

I’ll see you next week…

–bingo

Sunday musings 9/11/16

Sunday musings…

It was a Tuesday. For sure. Tuesday is an OR day for me, and I was with my work people on what looked to be a pretty vanilla Tuesday morning. That’s how you like it in the OR: vanilla. A good day is no memory of the operations whatsoever. A great day is one where you remember some interaction with your teammates, something good or funny or nice.

9/11 was definitely a Tuesday. What I remember is being with one group of my people.

Everything about the day was going just like every other Tuesday. Fast cases with great results. Stories flying back and forth between doc, nurses and patients. Just a joy to be doing my job. Until, that is, one of the nurses came into my room and said a plane had hit a tower. To a person our collective response was something like “huh…that’s weird. How tragic,” and then back to work. Back to normal until that very same nurse came back and said a second plane had hit the second tower. We all stopped after that case and headed to the family lounge, a TV and CNN.

I remember being in a similar place when the Challenger blew up, surrounded by colleagues, patients and families. That’s where I was when the first tower collapsed. After that nothing was normal about the day at all. There is literally nothin in my memory banks about the rest of the morning. I know we finished the cases, but then everything came to a full and complete stop. Clinic hours were cancelled, schools let out, and the wheels of American life ground to a halt. The rest of the day was spent in tracking down my brother (traveling now by car from Chicago to Connecticut), and best friend (stranded in Brazil). The skies were empty for days.

Our new normal had just kicked in.

My parents worried about an attack on our soil from Germany to the east (U-Boats off the coast of New England) or Japan from the west (a friend posted the story of a Japanese pilot who actually fire-bomb Oregon!). As a child our politics and our lives were spent worrying about the specter of a communist attack. As an adult, a father and a grandfather, it is now the fear of Jihad unleashed. The post-Reagan/post-Berlin Wall years of relative peace and security seem so very long ago now, don’t they?

The reality, of course, is that we are far safer than we think we are. Yet our own personal realities are driven by the same psychology that led our parents to fear a coastal invasion, for us to fear Russian bombers. We march on each day, as we must. We march on so that each day’s completion becomes one more tiny victory in yet another long war fought for us mostly between the ears, so much like the Cold War before it. We seek victory once again in the daily act of living our normal lives.

We remember, though. Like I remember that it was a Tuesday. We never forget, nor should we try to forget. It is in the remembering and carrying on despite the remembering that we do our tiny part to honor those who were lost. Today is a day to take a moment away from normal to remember.

I remember.

I’ll see you next week…

–bingo

Love For, and Loving From My Dog

Pets, dogs in particular, teach us some valuable lessons. We learn responsibility because they depend on us for the essentials of life. Every day we see what unconditional love looks like when we are smothered in puppy love upon awakening. Heck, we get it when we return from a 90 second errand. Some famous someone once noted that a dog is the only creature ever created that loves you more than in loves itself.

And we learn how to say goodbye. Our pets teach us that life is finite. Our love cannot change that, nor can theirs. Before we say goodbye to our people we typically have to say goodbye to one of our dogs. It’s a lousy, ouchy lesson; it’s a measure of their love for us that they typically handle it so much better than us. We are left with memories, and even here our dog teaches us about remembering our loved and lost.

Who, after all, really remembers anything truly bad about their dog?

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