Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘medicine’

The End of the Age of Volunteerism

Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by the actions of its historical recipients. Sunday marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left to toil alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. It’s cheaper that way. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

Innumerable examples are there for the picking. Some times it was just a case of laziness. Other times the insult was a clear effort to dump work on the volunteer. A critical care fellow requested a consult for acute narrow angle glaucoma. For those of you not medical this is one of the few “drop everything and go” consultations in eye care. When I arrived in the ICU I found a young patient with a black cornea who was mildly uncomfortable. I did what every highly experienced specialist does when they start a consultation, I asked the patient: “Hey, what’s up with your eye?” Turns out they had a blind, painful eye as the result of a surgical mishap, and surgery to remove the eye was already scheduled. Their discomfort was because none of the eye medications had been ordered; the fellow never asked. No doctor (or nurse) would have allowed this to happen in the Age of Volunteerism.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

We mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of whatever comes next.

 

Sunday musings 10/14/18

Sunday musings…

1) Feral. Abbie the Wonder Dog was feral for the first 6 or 9 months of her life. I can’t remember exactly. She was live-trapped and rehabilitated by a Border Collie rescue organization in north central Ohio. When she frustrates me it is always helpful to remember this.

Having a formerly feral creature living in our midst is also a very good counter to the frustrations of modern life. I try to remember how far I am from true privation whenever I find myself railing agains the insanity and inherent indifference that the world clearly has toward my existence.

A quick thought of my clever (read: sneaky) pup is usually all it takes to quell my urge to explode when I encounter the tragedy of a poor internet connection…while hurtling through a mountain pass in a car going 80 MPH.

2) Test. Some 10 years ago or so I proposed that a true measurement of health should be possible. Something that combined the most basic of classic medical knowledge (weight, %BW fat, BP, Cholesterol, etc.) and the breakthrough notion that physical fitness could be measured and tracked. My theory included the necessity of including some sort of measurement of “well-being”, a mandate that was initially openly mocked but seems to have been rather meekly accepted as both logical and necessary.

Creation and launch of such a value, call it “Total Health” or something along that line, has fizzled due to the lack of consensus–nay, even interest–in coming up with a way to measure Fitness. Imagine, in a place like CrossFit where the very definition of Fitness was created, no one save me and a tiny group of equal obsessives has so much as let fly a tiny trial balloon. The original owners of CrossFit LA were the first to use a standard entry test. 500M Row/40 Squats/30 Sit-Ups/20 Push-Ups/10 Pull-ups. I suggested pulling from both traditional sources (The President’s Fitness Test) as well as CrossFit and the larger endurance communities: 2:00 each of PU/Push-Up/Sit-Up/Squat, 1RM Deadlift, 1 mile Run. We ran a competition once called the “Fittest Eye Doc” using this.

What is necessary is a test that is a) doable by the general public, and b) capable of creating a single value that can be measured and tracked. Once that is done mathematicians and statisticians can be let loose with the various factors and given the task of coming up with a formula that includes all three categories. Why bring this here, again, when thus far my previous dozen or so postings have been met with crickets? With the pivot to health and the rapid build-up of a cadre of physicians who are at least superficially interested in using high intensity exercise for the purpose of increasing health, I am hopeful of a broader dialogue that comes to an agreement on a test.

Challenge: create a test of fitness that is broadly accessible in all ways (scalable) that can be included in a definition of health. 3-2-1…Go.

3) Volunteerism. Ladies and gentlemen, we are gathered here today to mourn the death of the Age of Volunteerism. While there exist tiny spaces where true volunteers live and thrive in a bilateral exchange of freely given goodwill, by and large volunteerism has been extinguished by its historical recipients. Today marks my last day ever of hospital ER call, the end of 2 years of receiving token payment for making my expertise available following 25 years of doing so for free. My experience is typical, as is this denouement.

Once upon a time all of your doctors were in private practice. We all had tiny little cottage businesses, did our work, and billed you or your insurance company for the work we did. Some of us worked in tiny little groups, but it was the rare doctor who was part of a large group or business whether in a big city or out in the country. Even the slickest Madison Avenue internist was basically a country doc, just with a better, more expensive wardrobe. In addition to having a greater familiarity with our patients we also enjoyed a very clubby relationship with all of the other doctors where we practiced. There was a collegiality, a sense that we were all in the struggle together. Folks who shirked their duties, foisting them off on other docs, were quickly educated about proper protocol or left alone.

Hospitals were different, too. Local or regional, they were hardly the gargantuan mega-businesses they’ve become. The org chart was shallow, and most local doctors were on a first name basis with the few administrators on the hospital payroll. You took call for the ER as a volunteer; the ER respected that you were donating your skill and your time and handled everything it could before calling you. Same thing for consultations. Your colleague only called you if they couldn’t figure out a problem or ran out beyond their scope of practice. There was a faint air of apology with each request, and a definite unspoken appreciation for the help that would be given. You helped because you were appreciated.

This is really no different from all manner of volunteerism in America. Smallish, closely knit organizations depending on the goodwill and generosity of members of their community pitching in to ensure success. Think local memorial 5K races, or CrossFit Games Regionals in the days before ESPN or the Home Depot Center. Countless small private schools that depended on the largesse and time offered by the families who sent their children there. You gladly accepted the opportunity to volunteer because you knew that without you the organization would not be able to function. You also knew that the recipient of your generosity not only appreciated your contribution, they really had no other options. Not only that, but if that organization somehow existed in your professional space you knew that it would never, not ever, abuse the trust necessary for volunteers to continue.

What happened? Money. Money and size and the distance that they create between an organization and its volunteers. Let’s go back to the hospital and the ER for a minute. Where once your efforts as a volunteer were deeply appreciated and those efforts rewarded with respect and care for your time and your expertise, the growth of employment of doctors by hospitals opened a gap between colleagues. No longer was there the esprit de corps, the shared notion that the primary target of our efforts was the patient was replaced by so very many doctors by the reality that they worked first for a business as faceless and uncaring as GM. Work that was once done by your colleague was now pushed to the volunteers whenever possible. Worse, boxes to be checked by the employed (to maximize revenue and minimize risk) meant demands made of volunteers, not requests. Worse, still, were discoveries that some “volunteers” were more equal than others: they were paid.

While this is nothing short of tragic in health care, it was inevitable once medical businesses were incentivized to grow ever larger. It is not confined to health care by any means. How do you think that volunteer at a Spartan Race feels when he learns how much his “team leader” is being paid? Have you ever “discovered” how much the Executive VP of your favorite professional organization is paid? As a people we Americans are generous to a fault. That generosity usually continues right up until we discover that we have been duped, and even worse that we have been purposely duped by the people who run the organizations for which we volunteer.

And so we gather here to mourn the passing of the Age of Volunteerism. Like so many things of wonder and goodness there remain pockets of resistance, little oases where the goodwill, honesty, and appreciation beget the kind of ebb and flow that made things so much better, kinder, more collegial at the apex of Volunteerism. My friend Tom Gardner was just named the president of the Society of Alumni of our Alma Mater. Tom has given tirelessly of his “spaces”, his timespace, brainspace and emotionalspace to help shepherd tiny Williams College as it flows on though time. Is this truly different? A tiny refuge from the Zombie Apocalypse of corporatization of all things to which we once volunteered?

We can only hope. Hope that Tom and those like him who continue to find places and causes where their volunteerism is met with what we in medicine have had to bid farewell. We can only hope that there will be places where being a volunteer means receiving the respect and appreciation and even a kind of love in return for what we have given. We can only hope that there will continue to be places where the incessant drive to grow ever bigger, size measured on a spreadsheet rather than by heart, will be resisted. For if it can happen in medicine, if volunteerism can be killed in what is arguably the most noble of all endeavors, I fear that it is doomed everywhere.

And so we mourn the end of the Age of Volunteerism. We wait with equal parts sadness and fear for arrival of what follows.

I’ll see you next week…

–bingo

 

DNA Always Wins

DNA always wins.

In the fitness world, and sometimes even at that tiny intersection where fitness and health or healthcare cross paths, there is a recurring theme: you can’t out-train a bad diet. For whatever it’s worth, I think that’s true. Having said so there is a dangling little assumption that hangs off the back end of our axiom, that if you are fit and follow an evidence-based nutrition program that you will inevitably be healthy. Indeed, every worthwhile fitness program I’ve ever encountered pretty much says just that. “Fitness in 100 Words” on CrossFit.com was my first exposure to this as a mission statement. Loads of folks from the substantive (The Brand X Method) to the frivolous (The Biggest Loser) support this logic as the foundation of health-based fitness. For the most part it is true, and for most people the combination of general physical fitness and solid nutritional strategy results in health.

Except, you know, the whole Jim Fixx thing.

For all of you puppies and kittens out there Jim Fixx was the original running guru in the United States, the author of The Joy Of Running. You could make a case that only the late, great Jack Lalanne was a more influential historical figure when it comes to promoting health through exercise in the U.S. Jim Fixx was responsible for the surge in interest in running as both exercise and as sport, and his writing launched an era in which U.S. runners were competitive on the international stage in ALL distances from the mile all the way to the marathon.

As it turns out Jim Fixx may also be the single most influential non-medical individual in the history of the cholesterol theory of heart disease. You see, Fixx had hereditary hyperlipidemia. Despite his epic running history he was found one day in his running shorts at the side of the road, dead from a massive heart attack. Blood work at the time of his autopsy revealed a cholesterol of 750 or something like that, as well as other elevated serum lipids. His healthy diet, his outsized VO2 Max, and his prodigious training schedule were no match for his DNA. He died with epic fitness numbers, a single-digit bodyweight fat %, and coronary arteries that were so clogged red blood cells had to pass single-file. You can trace many of the USDA dietary guidelines and literally billions of dollars in research to the death of Jim Fixx.

Why bring up Jim Fixx now, in 2018, when we know that hyperlipidemia is a significant part of the cardiac risk story, albeit not the whole story? Well, we should harken back to the beginning of my thoughts: DNA always wins. While you can reduce your health risks by adopting a healthy, evidence-based diet and couple that with an exercise program that produces a comprehensive degree of fitness, you cannot escape genetics. Why at this particular moment? Yours truly just got all of his lab work back and despite 13+ years of a clean Zone diet and varying degrees of devotion to functional fitness, most of my serum lipid numbers have continued on their ever-upward march and have now reached a level where they simply must be addressed by modern medicine.

To do else wise would be madness.

I must confess that this is deeply disappointing. Quite frankly it feels like failure. At 58 I am relatively lean and strong, albeit a bit under-trained in the aerobic domain. Why didn’t this inoculate me from the need to take medication to lower my LDL? In the last couple of days I have chatted with my docs locally (both of whom are close friends who care about me) as well as really significant, nationally recognized experts in the science of health and cardiac risk mitigation. There is a consensus; nay, the voting was unanimous across the board. Don’t be stupid. Continue my program of fitness and nutrition and take the meds. We’ve now moved on the the minutia of choosing which one, a not-trivial discussion to be sure, but one that is less than earth-moving, you know?

Some years ago while proposing a unified theory of health on my personal blog I received an advance copy of Coach Greg Glassman’s definition: if fitness is WCABTMD then health is Fitness Over Time. As a physician and scientist I readily saw the value of this concept. However, I also saw and pointed out the deficiencies inherent in such a narrow definition. For example, any definition of health must explicitly address mental health. Over the years I have championed the term “well-being” and have suggested several metrics that can be used to measure this state of mental and emotional health. Mind you, I was openly mocked at the time for this, here and elsewhere. If you have followed the conversation in the CrossFit world since you will see an evolution of thought along this line, though. “Well-being” has been openly discussed in various ways as an integral part of health in most medical, health, and fitness communities. I like to think I played a small role in that.

I wrote before, then, and subsequently over the years that any definition of health must be more than a snapshot of how “healthy” you may be at any given moment. You may have a 2.5X body weight deadlift and squat, run a sub 5:00 mile and do “Fran” in under 3:00, but can you truly be declared “healthy” if you also harbor a malignant tumor in your gut or are running around with an LDL of 175? Like it or not, any comprehensive definition of health must be able to provide some degree of probability that you will remain healthy in the future. It must have some predictive value. Traditional health metrics–blood pressure, lipid levels, family history, etc.–added to a measurement of fitness and well-being do just that.

In practice such a value has proven elusive for a number of reasons, none the leasts of which is the difficulty in designing a truly measurable variable for fitness that would be accessible to the masses. Once such a measure exists the rest is just math, right? It will be necessary to determine the relative value of our three variables–fitness, well-being, and risk predictors–and then plug them into a formula to kick out something that we might call “True Health”. While this is still “pie-in-the-sky” stuff I am convinced that it is only a matter of time before it is a reality. To do my part I have tried to enlist new “partners” like my brother-in-law Pete, the cardiology savant, and others.

But for now there are lessons to be learned from Jim Fixx, and yes, once again there is a teachable moment in my little epiphany and “Sunday musings” this week. You can’t out-train a poor diet. A healthy diet of any type combined with a program of functional fitness meant to produce general physical preparedness that includes both strength and metabolic conditioning is the optimal strategy. Even here, though, you cannot escape genetics. DNA always wins. Good, bad, or in between, your DNA talks to you in the language of traditional health risk metrics.

Your DNA doesn’t care how fast you can run a mile or how much you can bench. I start my new meds tomorrow.

 

Optimization vs. Diminishing Returns

Some time ago I wrote about the Minimum Effective Dose (MED), the concept in which we seek to optimize our results with the smallest amount of whatever it is that we are using to achieve that outcome. The quest to find the MED is one that crosses quite easily between my day job (medical) and my own quest for health (CrossFit). A quick mention of Eva T in Outside magazine and the program she uses with her clients made me think a bit more on the MED. The Everyday Math column in the WSJ provided an enhanced vocabulary for the journey.

Sometimes the MED really is a “something” you take. Here one thinks of medicine or food, for example. More often is the case that we are looking at a dose of time or effort. Or perhaps both. In this case we are seeking to optimize the effort as it relates to the outcome, to make the value of outcome divided by effort as large as possible. The rate limiting factor here is the Law of Diminishing Returns, of course: at some point additional effort produces such a small incremental increase in the outcome that it becomes not worth making. This applies to everything from WODs/week (or day) to decorating a birthday cake. At a certain point you just have to feel you’ve succeeded.

How, then, to know when you have reached this optimal level? Eugenia Cheng, the mathematician who wrote the WSJ piece, offers the concept of the “minimal acceptable standard”. Once she has reached this outcome the additional effects garnered from more effort have moved beyond the point where Diminishing Returns kicks in and she simply accepts the outcome. We would call these “minimal standards” goals, but the concept is essentially the same. We want an outcome; setting a target or a goal is step one in optimization.

Cheng then goes on to refine optimization with a discussion about boundaries. One is your goal, of course. In real life others also exist, things like a 24 hour day and a 7 day week and the need to make a living. The dose you choose, both qualitatively (what it is) and quantitatively (how much you get) is unavoidably affected by boundary conditions over which you have less control.In the end no outcome worth getting happens without effort. Health, friendship, or the unraveling of a gnarly math problem–you’re going to put effort in to get your results out.

Maximizing your outcome-to-effort ratio is just another way to say you are seeking your Minimum Effective Dose, in CrossFit and elsewhere.

Adventures in EMR Vol 2 Chapter 2: The War of the Roses

Unsportsmanlike conduct, piling on should have been the call, but alas, no flags were thrown. After roughly 15 months of crossing our fingers and hoping that our original EMR vendor would be able to guarantee our compliance with the twin pitchforks of ICD-10 and quality attesting it became clear to us that we could no longer afford our “spend and pray” strategy. We felt forced to initiate divorce proceedings with our legacy software and begin the search for a new program that would ensure our compliance, and in so doing allow SkyVision Centers to survive as an independent entity.

Well, that’s what we thought we were doing anyway.

Our original search for an EMR program in 2004 was undertaken from a position of strength in the skinniest of markets. There were only a few vendors who made a product suitable for eye care, and we were making a “want” buy rather than a “need” buy. In this position we had the luxury of working with the ultimate game plan: we could play to win. By this I mean we could clearly state what our objectives were and lay out in clear terms how we expected our new EMR to enhance our business. I mean enhance in every single manner, most definitely including the bottom line. Our search was meant to bring in technology that would not defend against loss but to help us bring in more revenue, to help us win.

SkyVision Centers entered the eye care market with a single, borderline maniacal focus on enhancing a patient’s experience in the office. Face it, there is no way that any but the most sophisticated patients are going to be able to differentiate between doctors and practices based on quality measures having to do with outcomes and safety. Our medical world is quite opaque in ways both inadvertent and purposeful. Discussing “bad doctors” or “bad hospitals” just isn’t done. By the same token, touting better outcomes or safer care is considered borderline slander by other doctors and institutions. Hence we simply considered all of this–quality, safety, etc.–to be the “table stake”, an assumption that each patient made, and we decided to set ourselves apart by our focus on how each patient FELT during their care.

If you think about this, we should also  be able to make all of these assumptions about something as basic as an EMR, right? That it should enhance both the doctor’s and the patient’s experience during care, or at least not have the opposite effect. Our original EMR was quick and efficient, was adaptable to our existing care and process protocols rather than the other way around, and allowed us to maintain eye contact with our patients for >90% of any care experience in the office. This, more than anything else, explains why I hung on for so long after any objective outsider would have already jumped ship to a new, regulatory compliant program.

It took precisely 90 seconds to realize that our patient-centered ideal was going to take a hit by changing our EMR. That’s how long I had to listen to the consensus best patient/doctor interface among the “modern”, compliant programs. Every single program arrives with a pre-set protocol, an indelible and unalterable set of mandatory processes that you WILL implement into your practice. Another 90 seconds spent reading the front page marketing pitch of this new batch of EMR candidates makes it clear that you are not looking at a program designed from the doctor/patient interface out to the billing office on its way to the payer. Every single product now sold that will comply with the various and sundry “quality” and reporting requirements is built from the billing interface back to your exam.

That’s an awfully tough pill to swallow.

Let me take just a minute to address the subject of scribes, staff members whose job it is to transfer the data that a doctor obtains and put it into the medical record. The solution to all of the problems created by EMRs is supposed to be solved by using scribes. Many (most?) doctors who are new to EMR are also new to the concept of using a scribe. Not so, though, in ophthalmology, at least at the level that I have practiced since I left residency training. For the most part I have had a scribe in the exam room with me from my very first day of practice. Our scribes were not just Carol Burnett Show era secretaries but highly trained technicians who simply rotated through their turn writing exam findings, diagnoses and plans with a pen on paper. I’ve always had this, and we utilized scribes in EMR v1.0 as well. Part of the unfairness was that I anticipated the need to hire MORE scribes simply to tend to the software’s protocols, so we were losing before the game even started.

What then does it mean to be playing “not to lose” when choosing the next EMR? The very first premise is little more than trying not to lose money you’ve earned by receiving a penalty for inadequate fidelity to all of those reporting rules. After that it becomes something more like trying not to lose your soul. Which program would allow us to maintain as much of our substance and our style while allowing us to continue to take care of the same number of patients? I was willing to forgo growth (loss #2 before game time). How long would it take for us to transition between platforms? Was there a program that would let us go fast enough that our patients would forgive us the obvious change in what it felt like to be in the office, even if that change was a 25-50% longer experience? I mean AFTER the transition. 25-50% longer in the office AFTER we are good at the new program. That was the reality I encountered in my search.

I’m not gonna lie. My biggest fear was that I would choose the wrong program. Well, check that; my biggest fear was that I would choose a program that would hurt us more than another one I might have chosen. I did my homework. I reached out to colleagues who do what I do and had chosen an EMR in the last 3 years. I went into offices and watched staff members and doctors use the programs I looked at. It was unbelievably depressing in all honesty. The lack of eye contact with patients and the slavish attention demanded by the computers in the room was appalling, not to mention the drudgery. Death by a thousand clicks.

Check that. A million clicks.

A consensus arose among eye doctors, one that I agreed with, that there are two EMR products on the market that are better than all of the other options, and that it is essentially a toss-up between them. Every colleague I chatted with felt this way, including those who were content with their present programs; they would choose one of the two (and not their present program) if they were starting from scratch. After narrowing down my choice to two it was almost a coin toss to be truthful.

After pouring lots of money into that car I already had in the hope of returning it to functionality I was ready to buy a new car. To spend yet more money on one of the two choices before me. No matter which one I chose, I was choosing something that would mean an existential change in how we practiced medicine at SkyVision Centers. Because there were only two, no matter which one I chose I would forever be haunted by the question of whether life might have been just a bit less unpleasant if I’d chosen the other one.

Changing your EMR because you have to is like the War of the Roses: there is no winning or losing, there are only degrees of losing.

Next Chapter 3: Jogging in Quicksand (where only the “A” counts in SOAP)

Better Understanding Conflict of Interest By Studying Bias

So much strum und drang in the air. So many panties in a bunch. The offensitive are on the warpath about, well, everything. We seem to have a surfeit of ethicists among us, proclaiming in nearly real time where anything and everything fits on some mythical ethics grid. To them I offer my own filter, the question I ask before I expend an iota of energy of any kind on the type of “news” that has them all so agitated:

Is what I am viewing unethical, or simply unseemly?

Ethics is a synonym for morals. As such it should be universal and timeless. Ethics should bear nothing in common with fashion.

Speaking of which, it is fashionable in pretty much any field in which expertise can be obtained and the label “expert” attained to lay waste to those so acclaimed by accusing them of having a “conflict of interest”. Traditionally this meant that one might enjoy some sort of tangible gain by trafficking in one’s area of expertise, thereby rendering the expert’s stated opinions somehow tainted. Of late it means that being employed by someone with whom your critic has a beef means your standing to hold an opinion at all is nullified.

Nonsense.

We would be a wiser society if we instead made an effort to sort through the biases held by experts in any field. To demand that one not express any opinion that would support your employ should disqualify the individual who holds such a position, not the expert. To look at the bias that may be present in any expert opinion allows the audience to better evaluate both the veracity of the opinion, as well as its relevance to their own situation. For example, in my day job I have a strong bias to treat any condition that produces meaningful symptoms in my patients.

In truth, in many of the general categories that I cover my remuneration is identical whether or not I treat. Those who bleat on about conflict of interest would seek to nullify all of my thoughts simply because I make my living in the arena on which I opine. Again, this is silly. It is far more useful to read my professional writing through the prism of my pro-treatment bias. In so doing it is far easier to compare and contrast my public opinions with others in my space who may differ. Do they differ on substance, or do they differ because or a countervailing bias?

This is not to say that conflicts of interest do not exist, or that if they do exist that they are never a problem. If you have invented a medical device and choose to use your own device rather than a competitor’s you have a COI. Disclosure of your COI should be mandatory (I disclose all consulting contracts around prescription drugs, for example). If they are of equal quality (equal safety, equivalent outcomes), the COI is mooted. If your device is much more expensive (thereby generating much more income to you), your conflict of interest is unseemly but not necessarily unethical. It should be obvious on its face that using your invention if it is less effective (or Heaven forbid, unsafe) is unethical.

Expertise exists everywhere. Here, on CrossFit.com in the fitness world. Would you disqualify Greg Glassman because CrossFit has been a successful business? How about Jeff and Mikki Martin who have launched a business in the same space? Is their competition a conflict that nullifies their contributions to youth fitness? Among the bureaucrats at the EPA in the care of the environment. Do they not have a contribution to make despite their tax-supported position? Is their (presumed) anti-business bias a reason to dismiss all federal policy? Among the various and sundry talking heads on all of the financial offerings on cable news channels. Don’t you really want them to be rich and successful, especially if you are going to follow their advice?

If we seek to understand the biases that exist underneath the opinions of experts we can better evaluate the conflicts of interest that they inevitably carry along with those opinions. From there is is an easier task to evaluate the character of those conflicts, and better decide whether or not we accept their guidance.

Getting paid to be an expert and to share your expertise is only a meaningful conflict of interest if it is unseemly or unethical, not just unfashionable.

 

Why Private Practice Survives

“I’m surprised these kind of places are still open.” –Physician employed by World Class Medical Center

“And yet, here you are, bringing your mother in for a visit.” Technician checking in mother.

In my day job I am an ophthalmologist, an eye doctor who takes care of medical and surgical diseases of the eye. Our practice, SkyVision Centers, is an independent practice, what is often referred to as a “private practice”. As such we are neither connected nor beholden to either of the large organizations here in Cleveland, both of which have large ophthalmology practices with offices near us. The mother in question was originally seen on a Sunday in my office through an ER call for a relatively minor (but admittedly irritating) problem that had been ongoing for at least a week.

That is not a typo; an ophthalmologist saw a non-acute problem on a Sunday.

Now Dr. Daughter swears that she tried to get her Mom in to see a doctor all the previous week. “She” even called our office (more in a moment) and was told all of the doctors were booked. Strictly speaking, the staff member who answered the phone was absolutely correct in noting that our schedules were full (actually they were quite over-booked in the pre-Holiday rush), and that we would not be able to see a patient who had never been to our office. Dr. Daughter works for a massive health system that advertises all over town–on billboards, in print, on the radio and online–that anyone can get a same-day appointment with any kind of doctor in the system, including an eye doctor. In fact, we saw several dozen existing patients that week for same-day requested ER or urgent visits with the urgency determined by the patient, not our triage staff.

What’s my point? Dr. Daughter never made a single phone call. She had one of her staff members call on behalf of her mother; neither I nor my staff is responsive to proxy calls from staff. I know Dr. Daughter and much of her extended family. Over 25 years practicing in the same geographic area and populating the same physician panels she has sent me barely a handful of patients, even though I care for a substantial majority of that extended family. Despite that my staff would have moved Heaven and earth to find a spot for Mrs. Mom if Dr. Daughter had called either my office or me personally.

I know what you’re thinking: Mrs. Mom would get in because her daughter is a doctor. Nope. Not the case. I may have taken Dr. Daughter’s phone call for that reason, sure, but Mrs. Mom gets an on-demand ER visit despite it being our busiest time of the year because she is the family member of other existing patients. We treat family members as if they are already SkyVision patients; we just haven’t officially met them yet.

Now you’re thinking “what does this have to do with private practice?” Without meaning to be either too snarky or self-congratulatory, this is precisely why private practice continues to not only survive, but in many cases thrive. We have the privilege of putting our patients first. Really doing it. Same day urgent visits? No need to put it up on a billboard; we just answer the phone and say ‘yes’. Lest you think we are simply filling empty slots, or that we have open ER slots we leave in the schedule just in case, let me assure you that this couldn’t be further from the truth. We. Are. Booked.

Well, it must be that we are so small that the personal touch is easy. Surely if we were huge we couldn’t get away with this. Sorry, wrong again. A bunch of my buddies are orthopedic surgeons in a massive private group on our side of town. Like 15 docs massive, with all of the staff you’d expect to go along with that many doctors. Got an orthopedic emergency? You’re in. You may not get the exact doctor you’ve seen before on that first visit, but you won’t be shunted to either an ER or an office an hour away, either. The staff members making appointments for a particular office are right there, sitting up front. The same goes for the enormous Retina practice that spans 4 counties here in Northeast Ohio. Ditto for the tiny little 3-man primary care practice up the street from me, lest you think only specialists do this.

The private practice of medicine survives because the doctors go to work for their patients, and they don’t leave until the work is done. Private practice docs bend their own rules on behalf of those patients. Every day and every night. You know what happens when private practices are acquired by massive medical groups like the two 800 lb. gorillas in Cleveland? All of those rules get made by people who don’t really take care of patients at all, and they never bend a single rule ever. Those former private practice doctors become shift workers beholden to an institution, no longer working for their patients at all.

That family doctor or specialist who was routinely asked on a daily basis if someone could be squeezed in is not only no longer asked, she doesn’t even know the question was there in the first place. Everything is handled by the institution’s call center, somewhere off in a lower rent district, with no sense of what is happening at that moment in the clinic. Your doctor might have a cancellation and a spot open to see your emergency. Indeed, if she’s been your doctor for a long time she would probably rather see you herself because that would make for better care.  But there are now someone else’s rules to follow, efficiencies to achieve so that they can be touted, and institutional numbers to hit.

“I’m surprised these kind of places are still open.”

“And yet, here you are, bringing your mother in for a visit.”

On her way out, after impatiently waiting while her mother thanked me profusely for seeing her when she was uncomfortable, Dr. Daughter extolled the virtues of her employer. Fixed hours. Minimal to no evening or weekend call duty. A magnificent pension plan that vests rather quickly. I should join up, she said. She was sure that World Class Medical Center would love to have me.

I smiled and wished her, her Mom, and the extended family a Happy Holiday Season. As I turned, shaking my head a bit, my technician put her hand on my arm.

“If you did that, who would take care of her Mom?”

Equal Pay for Equal Work: Medicine is the Perfect Laboratory

The endless debates about the “Pay Gap” between men and women in the United States drones on. Today is “Equal Pay Day”, kinda like “Tax Day”, the day when you stop paying the government and instead start paying yourself, only it’s the day when the “average” woman supposedly has to wait for before she starts to make what a man makes. It all makes for great spectacle and epic barstool arguments for the same reason that people argue about who’s greater, Michael or Elgin, Kareem or Russell, The Babe or Barry: there is no proper, standard way to measure the issue at hand. On a barstool arguing “greatest ever” you never agree on either the definition of “greatest”, nor can you account for the vast differences in historical eras.

So it is with the pay gap. No one agrees on what constitutes work, let alone equal work.

This creates the maddening situation in which we find ourselves now whenever this comes up for discussion. Absent a meaningful definition of either “work” or “equal” we are left with folks on all possible sides of the issue simply choosing whatever statistic will support their deeply held beliefs about the issue. It’s crazy, actually. I read a dozen citations today and each one was so deeply flawed that it couldn’t stand the scrutiny of the middle if you velcroed it to the  50 yard line. Work is invariably conflated with “hours worked” with no discernible effort made to investigate something like intensity, or the measurable work performed per unit of time. “Equal” work is just a quagmire of competing opinions with, again, no effort whatsoever at objective measurement. How can you have a discussion that is meant to conclude with some sort of actionable agreement when all you do is pull numbers out of the ether and throw them at each other?

While engaging in a sorta, kinda conversation about this on Twitter it struck me that I actually live and work in the perfect laboratory to investigate the issue of the Pay Gap between men and women. You see, we have reams of objective data that can be evaluated. We all, men and women, do exactly the same things if we have the same jobs. Not only that but we have a unit of measurement for that work, the RVU. If Dr. Darrell does a cataract surgery and Dr. Dora does a cataract surgery, we have both done the same job. We can even determine the “intensity” of our work, our output if you will. A simple survey of hours worked per day can generate the metric: RVU/hour. Better yet, don’t take my word for it in a survey, just look at that heretofore meaningless and useless EMR and look at the measured time Darrell and Dora took to do their work. The OR record is a precise measurement of how much work we did per unit of time.

This is powerful stuff. Work is defined. An appendectomy is an appendectomy. A Level 4 New Patient Office Encounter is a Level 4…you get the idea. You get to compare apples to apples, heck, you get to compare Honeycrisp apples to Honeycrisp apples. It doesn’t matter if you are a man or woman or transgender. White, Black, Brown, Yellow, Red (did I miss anyone?), Millennial, Boomer and everything in between, work is work and an RVU is an RVU. Heck, you could gather all of the information about the work without anyone knowing who did it until after it’s all together. We could have a big unveiling when we lift the blinders and see who did what and how much they did. Seriously, how cool is this? It would almost be like science.

Let’s do be a bit serious for a moment. Imagine what kind of information we could acquire and what kinds of questions we could ask and answer. For sure there will be very reasonable concerns about how much we will be able to extrapolate from medicine to other areas of employment (advertising, investment banking, etc.), but it’s a great place to start. The question of the Gender Gap is primary, but how about looking at work across the generations. There is a “feeling” in medicine, certainly among crusty old folks in my generation, that younger physicians of both genders work fewer hours and do less work per hour when they do work. Is that true? It sure looks like it would be easy to answer that one, too.

There are actually a number of other issues in medicine that would be clarified if we had this kind of data, at least insofar as the work done is concerned. For example, how do private practitioners stack up against salaried physicians in large groups? Is there a correlation between how those salaries are determined and the intensity of work done? We can also look at value, work done per dollar paid (again, assuming equal outcomes). Where are we getting the best bang for our buck? For that matter, with the EMR’s that never sleep we can actually look at the responsiveness of doctors to their patients in urgent or emergent circumstances. Is there one group (men vs. women, private practice vs. employed) who are more responsive?

Having a discussion that is based on hard definitions of terms and data-driven rather than belief-driven opens up a whole world of meaningful inquiry.

Once upon a time I was among the highest paid physicians in the U.S. I worked insane hours, and the intensity of my hourly output was off the charts. In a word, I earned every penny I made, and the fact that I made more than another ophthalmologist had nothing to do with the fact that I was a man. Funny thing though–I now make a fraction of what I once made because I don’t work as much as I once did. The intensity of my work is similar; I still do as much work per unit of time, and my ability to perform at this high level of intensity is still greater than 95% of my peers, I just work fewer hours. What are we to say about women who do what I do, work more hours than I do, and yet do less work? Is there a gender gap in pay if I make more money than they do? What are we to say about my ambitious female colleagues who work more hours than I and work at the same intensity? I’m firmly stating that they should make more than I do. Is that the reality on the ground?

In medicine we have the ability to answer this question in a very objective, non-ideological way. I don’t know if what we find will be something we can extrapolate to other jobs, especially if we find that pay is directly related to actual work done in a domain where work can be both defined and measured. But hey, it’s a start. And it’s way better than just playing emotional whack-a-mole with how we value what we all do.

 

Measuring Health Part 4: Fitness ‘F’

Health should be defined along the lines of individual human potential. An actionable definition would go something like “the ability to live at the limits of your fullest potential without any encumbrance now or in a foreseeable future”. Fitness as defined by Greg Glassman and CrossFit–work capacity across broad time and modal domains–should therefore be seen as “applied health”. As such, since fitness at any given time is an accurate measurement of one’s functional ability, our variable ‘F’ should have the heaviest weighting in our Health Index.

Let us begin our discussion of Fitness by reviewing and dispelling several myths and misconceptions about the interrelation between health and fitness. First, is it really necessary to review all of the data which now stares us in the face as far as the importance of exercise in health? By the same token, it should be clear to any sentient being that not only is what we eat important (although we must concede that this may differ across populations) but how much?  Simple carbohydrates, manufactured substances meant to cheaply replace real food, harmful (trans-) fats–it doesn’t matter what KIND of nutrition plan you follow, these are all BAD. As I write this I am recovering from surgery and I am not able to exercise. Does anyone believe that I will NOT gain useless weight if I maintain my pre-operative food intake? This part isn’t rocket science, folks. Coach Glassman says it as well as anyone: “Eat [protein] and vegetables, nuts and seeds, some fruit, little starch, and no sugar. Keep intake to levels that will support exercise but not body fat.”

Next up is the canard that fitness is simply being able to do something for a very long time. This view, promulgated and propagated by the likes of Outside Magazine and others, is not only insufficient but has been shown to be false as well. In the last couple of years there have been a number of very important studies showing a degradation of heart function in so-called “Ultra” athletes in any area. Decreased cardiac output and an increase in cardiac arrhythmias such as atrial fibrillation have been shown to be caused by excess endurance training. Endurance as the sole defining characteristic of fitness is as incomplete as would be strength. One need only look at the life expectancy of the strongest humans on record to see that strength in and of itself is not sufficient to produce health.

The question of what constitutes fitness is one that has been answered, at least insofar as health is concerned. It is not enough to be able to run or bike or swim long distances if you cannot also lift heavy things, including your own body. In the same vein one is not truly fit if one can deadlift or squat 3X his or her own bodyweight but cannot run a mile in under 15:00. One must have some measure of BOTH. As such the inescapable conclusion is that Greg Glassman is correct when he says that fitness equals work capacity across broad time and modal domains. You must be able to lift heavy things over a short distance when necessary, but also possess the ability to carry lighter things a longer way for a longer time as well. While I am not naive enough to expect that this will be accepted without spirited debate, when it comes to any measurements of health now available, all arguments to the contrary are not supportable. Glassman has won this battle.

As an aside, this should once and for all put to rest the myth of the “healthy obese”. What good is it to be happy, ‘W’ off the charts, with a stratospheric ‘M’ because all of your bloodwork is perfect, to go with your BP of 120/70, if your joints will cave under pressure decades sooner than they need to? You simply cannot escape the reality that health requires physical fitness.

If fitness can be described as “applied health”, it stands to reason that it will have the greatest contribution to our eventual Health Index. As such it is especially important that our chosen tests meet the criteria outlined in Part 1, that the measurement be as broadly accessible in all ways as possible. In the purest sense we would be able to measure an individual’s “work capacity”, the totality of his or her expression of fitness as measured by many tests covering different loads, distances traveled, and time. In CrossFit we talk of this as the “area under the curve” of a graph that records Power (lbs-ft. per second) on the X axis and Time (in minutes) on the Y. In a perfect world this would be part of every individuals ongoing pursuit of health, but alas, even in the CrossFit world where a very committed everyone records everything, this has proven to be problematic. In designing a series of tests to be applied to the broadest possible swath of humanity this ideal must yield to a more pragmatic approach.

What, then, should we measure, and how? Let us first propose a couple of general characteristics of the tasks in our test and then see what fits the bill. We should test an individual’s ability to move from one place to another under their own power–running is a fundamental human trait and should be part of our evaluation. Likewise, the ability to pick something up off the ground is a pretty basic, everyday movement and would qualify as our test of strength. Lastly, in the U.S. we have a storied heritage from the 1960′s, The Presidential Council Fitness Challenge (PCFC), in which candidates are tested on their ability to perform calisthenic exercises for both speed and endurance. It would be fitting to include something that evokes this historical element.

Once again I anticipate a vigorous debate about the particular elements we include. I’ll go first. We can reward both speed and endurance by starting with a timed run in which the result is distance traveled. The most common example of this comes from athletic programs and the military: a 12:00 timed run for distance. We live in the U.S.; the unit is yards. Pick up something heavy? Sure sounds like a deadlift to me. Any deadlift you wish, standard or sumo, will do. My bias is that a lifting belt is just fine, but except in very special circumstances (e.g. one-armed subject) I would say that straps to help you grip the bar are not a good idea, especially for the very inexperienced subject.

After giving considerable thought to the exercises and format in the original PCFC I think we should simplify the test while at the same time bringing it into the modern fitness world. In the PCFC one sought a maximum number of reps in 2:00 of pull-ups, 2:00 of sit-ups, and 2:00 of push-ups. What exactly are we testing with sit-ups that reflects true fitness? I would favor swapping out sit-ups for air squats. With a nod to CrossFit and Greg Glassman’s outsized contributions to this discussion, let’s use the format made famous by the CrossFit WOD “Cindy” with a small adjustment. To test our subject’s ability to perform bodyweight movements and move quickly, repeats of the triplet of 5 pull-ups, 10 push-ups, and 15 air squats in 6:00, counting as our result the total number of repitions achieved.

There you have it. A definition of “Health” and “Healthy”. The introduction of the three variables that go into the measurement of “Health”: traditional medical values ‘M’, emotional well-being ‘W’, and Fitness ‘F’. Next I will address how we will value each of these measures, and then ultimately how they will be combined to give us a meaningful, actionable health measurement ‘H’.

 

Measuring Health Part 2:The Traditional Metric ‘M’

Any measurement of health must provide some sort of predictive value with regard to the likelihood that one will remain healthy. While the entire idea of screening tests is fraught with controversy–both false positives and false negatives bring with them real risks–there are still a number of health measurements in the realm of traditional medical care that have a proven value when trying to predict downstream adverse health events. The trick, of course, is to decide which ones matter, filter that group to come up with tests that are as close to universally available as possible, and then decide how much weight each particular test in the group of survivors should receive in the single cumulative metric that is then created. This measurement, call it “M”, will be one of the variables in our calculated health measurement.

Let’s start with the simplest of all medical inquiries, a medical history. More specifically, let’s include a brief family history in our calculation of M. While it is becoming increasingly easy to obtain a very accurate genetic profile that identifies very specific health risks, these genetic tests are both controversial and expensive. Until the very real societal issues of knowing your exact genome and the risks it includes have been worked out by both ethicists and elected government, we should take a simpler and more narrow approach and ask two very simple questions: Has anyone in your family died from heart disease? Has anyone in your family died from cancer? Equally simple follow-up questions (How young were they? What kind of cancer) would allow us to add risk (reduce M) or ignore the historical note since the disease is not hereditary.

From here we move to an equally spartan individual medical history. Again, just two questions in this part: Do you smoke? Do you drink alcohol? The negative effect of smoking on an individual’s health, both in the present and future tense, must be accounted for in any measurement of health. It weighs so heavily on what we know about future risks that we will see it as a negative integer in M. Too many studies to count exist pointing out the deleterious effect of excess alcohol consumption to count. One compelling study, The Eight Americas Study in PloS One, found alcoholism to be the single most powerful lifestyle variant after smoking when predicting the life expectancy of groups studied. A recently published study of Harvard men found that alcoholism was the greatest second greatest influence on the happiness of the men studied, just behind the presence of loving friendships. Unlike smoking, however, there is a volume component to alcohol consumption. Indeed, a modest intake actually INCREASES longevity, while no intake DECREASES longevity. So M will see a small bump from moderated alcohol intake, an equally small decrease for teetotalers, and a dramatic negative effect from heavy alcohol intake.

So far we’ve managed to obtain some variables underlying M through the use of simple inquiry, costing only the time it takes a subject to fill out a questionnaire. At least two other variables are as accessible and inexpensive: blood pressure (BP) and a measurement of body habits. Once upon a time you had to visit a doctor or hospital to get your blood pressure checked. Now? Heck, for $20 you can buy a reasonable accurate BP monitor and take your BP at home! Minute Clinics in pharmacies, health clinics in the workplace, and coin-operated machines in the local Mall now make it easy to get a BP without visiting a doctor. While there is ongoing controversy in the medical world about what constitutes Hypertension it is safe to say that health risks are higher with a systolic pressure >140 and a diastolic >90. Above or below these levels is our toggle for M, positive or more healthy for lower and the opposite for higher BP.

Using body habitus is controversial, mostly because the measurement that is routinely utilized is so inadequate. The Body Mass Index, or BMI, is wildly inaccurate when it is applied to the fit. 4-time winner of the CrossFit Games Rich Froning, arguably the fittest man on the planet, would be deemed obese at 5′ 10″ and roughly 195 pounds with a % body weight fat of around 4%. Ridiculous, huh? The temptation, of course, is to use % BW fat as the preferred method of measuring body composition risk, but measurements that are accurate enough to be useful tend to be very expensive and difficult to access. On the other hand, all you need to determine the waist/hip ratio is an 89 cent paper tape measure and a calculator. A waist/hip ratio of >1.0 is associated with an increased risk to health from myriad metabolic illnesses including diabetes and heart disease, especially in men. Greater health in M for measurements under 1.0, and progressively less as that number increases.

It is impossible to utilize all that modern medicine has to offer when it comes to measuring health without spending a little bit of money. Several simple blood tests can be obtained with or without the input of a physician. The presence or control of diabetes can be ascertained with a HbA1c and a fasting glucose level. In the presence of a normal HbA1c an elevated fasting glucose may indicate a problem with insulin sensitivity, so it is important to include both. While it is far from settled whether or not it is cholesterol itself which is responsible for heart disease there is simply too much evidence that serum lipids can help predict cardiac events to leave them out of any health measurement. Our basic health index should therefore include the basic measurement of total cholesterol, HDL, LDL, and triglycerides, and M should reflect the negative effect of elevated Total Cholesterol, LDL and triglycerides and the positive effect of a high HDL.

How should we put all of these together to come up with our traditional health variable, M? This one is fairly simple; there are a number of “risk factor” measurements online that are good models. I envision a rather simple form on which one would add up weighted values for the measurements above, arriving at a straight forward mathematical sum. The final formula is being developed with the assistance of cardiologists at my medical school alma mater, the University of Vermont.