OP-ED

Art Caplan 2Why are they so afraid of public health types who want to do something about the carnage caused by guns in America?

Vik Khanna is the latest man with a gun to write squealing in terror  before the kale crunching, fitbit wearing hordes of public health types who he is somehow sure are out to disarm him and, even more hilariously, have any chance of doing so.

Vik, buddy, no one and especially the roughly 28 folks in public health not completely distracted by their lack of funding and inability to secure tenure is capable of doing anything that will pry your gun from your warm-blooded grip. There is no political movement to take away anyone’s guns. The NRA is the mightiest lobbying outfit in these United States and the best Mike Bloomberg or Bill Gates are going to be able to do is to get the anti-gun lobby a few more op-eds and soundbites.

Vik stop being afraid of your critics. You hold all the bullets er … cards. Time to think harder. Do public health folks have anything to offer that might reduce the mayhem while letting you hunt deer or shoot partridge or blast targets or whatever it is you and your son like to do with your guns?

Well yes in fact there are some things from the minds of the unarmed weenies of public health worth your consideration and that of your open-carry pals.

Continue reading “What Is It With Gun Rights Proponents?”

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The Future Looks Like a Girl With a Gun Resized

I am a public health professional, educated at the vaunted Johns Hopkins University Bloomberg School of Hygiene and Public Health. I like guns, and I believe the Second Amendment clearly secures the rights of individuals to own firearms.

You read that correctly. I am a public health professional.

And I like guns.

This make me a heretic in American public health, where embracing firearms and the rights of gun owners is a gross violation of orthodoxy.

As a society, our focus on guns and not gun users derives from the shock of mass killings, such as those in Newtown, CT, Aurora, CO, Virginia Tech, and Norway, which has some of the strictest gun control laws on the planet. Mass killings, however tragic, get distorted by saturation media hysterics and 24-hour political grandstanding. What gun opponents refuse to discuss is the precipitous fall in violent crime and deaths by firearms over the past 20 years, and how it coincides with an equally dramatic increase of guns in circulation in the US.

While that isn’t cause and effect, the association is certainly curious.

In 2013, the Institute of Medicine, at the behest of the Centers for Disease Control, produced a report on firearms violence that has been ignored by the mainstream media. The upshot: defensive use of firearms occurs much more frequently than is recognized, “can be an important crime deterrent,” and unauthorized  possession (read: by someone other than the lawful owner) of a firearm is a crucial driver of firearms violence.

That report went away for political reasons. Translation. Nobody wanted to talk about it because it raised more questions than it answered.

Continue reading “Why Public Health Needs a New Gun Doctrine”

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flying cadeuciiTo appreciate the potential impact of the startup movement on health and medicine, you really need look no further than Drs. Rushika Fernandopulle and Farzad Mostashari (disclosure: I was colleagues with both at college and later at MGH).

Both are passionate about transforming healthcare – Fernandopulle has an M.D. and a public policy degree from Harvard, and was the first executive director of the Harvard Interfaculty Program for Health Systems Improvement; Mostashari served as Assistant Commissioner for NYC’s Department of Health, and more recently as the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services in the Obama administration.  Both are committed to improving the delivery of patient care.  And both have deliberately chosen to pursue their vision by creating a company as the vehicle to deliver the change they each believe in.

“The world of start-ups may not be the usual path for those leaving a senior federal post,” wroteMostashari about his new direction, “but it’s the right decision.”

Last month, Mostashari founded Aledade, which seeks to enable independent, primary care physicians to establish accountable care organizations.

A few years earlier, in 2010, Fernandopulle co-founded Iora Health, aninnovative model of direct primary care, and continues to serve as CEO.

Explains Fernandopulle,

“As a practicing physician it soon became obvious our current model of care delivery does not work; instead of simply complaining about it I felt I needed to try to fix it, but got frustrated trying to do it within existing health systems, and found studying the problem (in academics), working through the government, and consulting was not effective. I decided that the best way to make change happen quickly was to simply strike out myself and just do it- being an entrepreneur allows you to break what others think are the rules (they aren’t) and take change into your own hands.”

Fernandopulle and Mostashari aren’t alone – across the country (and the world), physicians from every specialty are creating, joining, or hoping to joinstartups.  While many of these doctors are fairly junior, and have little (if any) substantive clinical experience, some are more seasoned – HealthLoop’s Jordan Shlain comes to mind, for example.

Continue reading “Why Physicians Are Turning to Startups”

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flying cadeucii88.2 % of all statistics are made up on the spot
- Victor Reeves

There’s a growing movement in medicine in general and imaging in particular which wishes to attach a number to everything.

It no longer suffices to say: “you’re at moderate risk for pulmonary embolism (PE).”

We must quantify our qualification.

Either by an interval. “Your chances of PE are between 15 and 45 %.”

Or, preferably, a point estimate. “You have a 15 % chance of PE.”

If we can throw a decimal point, even better. “You have a 15.2 % chance of PE.”

The rationale is that numbers empower patients to make a more informed choice, optimizing patient-centered medicine and improving outcomes.

Sounds reasonable enough. Although I find it difficult to believe that patients will have this conversation with their physicians.

“Thank god doctor my risk of PE is 15.1 % not 15.2 %. Otherwise I’d be in real trouble.”

What’s the allure of precision? Let’s understand certain terms: risk and uncertainty; prediction and prophesy.

By certainty I mean one hundred percent certainty. Opposite of certainty is uncertainty. Frank Knight, the economist, divided uncertainty to Knightian risk and Knightian uncertainty (1).

What’s Knightian risk?

If you toss a double-headed coin you’re certain of heads. If you toss a coin with head on one and tail on the other side, chance of a head is 50 %, assuming it’s a fair coin toss. Although you don’t know for certain that the toss will yield head or tail, you do know for certain that the chance of a head is 50 %. This can be verified by multiple tosses.

Continue reading “The Quantified Doctor”

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Screen Shot 2014-08-29 at 8.33.53 AM
US Healthcare is sick and getting sicker, and while its chaotic complexity suggests to many that it will need to fail big before it can be rebuilt, some simple rules may help to get it back on track. As this the time of year when many of us prepare to send our children on grandchildren off to school in the hopes that they will learn what they need to succeed, I thought we could revisit the lessons of Kindergarten and their application to healthcare. The following list, initially from “ALL I REALLY NEED TO KNOW I LEARNED IN KINDERGARTEN” by Robert Fulghum.  has been adapted (read ‘man-handled’) for applicability to US healthcare. You’ll find the original list here:  http://www.robertfulghum.com/

  • Share everything – In healthcare, this means share ALL the data, all the information, all the acquired wisdom. Interoperable systems are essential. Price transparency is the right side of history. Automated, coordinated, connected systems are essential.  Healthcare is too much of a team sport not to share all that we know, so that we can quickly understand what works, what doesn’t, and what it’s all going to cost.
  • Play fair – It isn’t fair when decisions are made without a person’s input.  It isn’t fair that a patient should bear the risks, the pain, the scars and the costs without having unfettered access to all the relevant information. Shared decision making is part of playing fair in a world where healthcare is meant to happen for patients and with patients, but not to patients.
  • Put things back where you found them. Except for things like an infected appendix or a malignant growth, this continues to make great sense.  And as we go about transforming healthcare, we must recognize that wholesale, sweeping changes are easier to envision than execute.  While progress requires change those changes that align with / enhance / expedite existing workflows will be easiest to achieve.
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Screen Shot 2014-08-28 at 11.38.01 AMIn the past few years, we’ve seen headline after headline marveling at the advancements of medical technology. From wearable tech and micro sensors to 3D printing and health-oriented apps, it’s evident that technology and medicine have merged into an industry that’s pushing healthcare to a new level.

Yet many in the health tech industry are also voicing concerns about government regulators and their standards for healthcare technology. Some have even gone as far as accusing the FDA of “stifling” the creativity of healthcare tech and hindering the value these devices and apps could bring to the public.

In early 2014, legislation was introduced in an attempt to redesign the regulatory framework for certain types of technologies and lessen the FDA’s control over this growing industry. But are the FDA’s standards and actions so bad?

I’m in the tech field myself, and while I’ve heard many arguments against the FDA’s regulations, I strongly feel that it’s completely within its rights as a regulatory agency to place limits on medical technology. The FDA’s standards are put in place to protect consumers and to correct disingenuous manufacturer claims — an alarmingly frequent trend in today’s digital world.

Continue reading “Are Federal Regulations Stifling Disruptive Healthcare Technologies in the US?”

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Screen Shot 2014-08-22 at 9.26.00 AMThis week a host of organizations responded to a Senate Finance Committee request for feedback on how to better use healthcare data.

The inquiry is timely, given the widespread frustration providers have with health information technology (HIT), and electronic health records (EHR) systems in particular. This frustration stems from many HIT/EHR systems are locked in proprietary systems. This hinders technology’s ability to connect and exchange information freely between disparate systems, devices and sensors along the care continuum, thus undermining the overall goal of using HIT to improve efficiencies and reduce costs.

An example illustrates the point. Because HIT systems don’t work together, most hospitals use nurses to manually double check input from disparate “smart” devices. For instance, an infusion pump reports the level of pain medication being administered to a patient, as does the EHR. But these numbers sometimes don’t match, and must be double checked by at least two nurses to confirm the right dosing. Not only is this a step back for efficiency, but it’s also another manual process that has the potential to create errors and patient safety issues.

There are also economic consequences of data fragmentation. According to the Office of the National Coordinator (ONC), U.S. providers are spending $8 billion a year due to the lack of interoperability.

To address this problem and reduce the unnecessary fragmentation of healthcare data, it’s time to require the use of open and secure applications programming interfaces (APIs).

In April, a group of America’s leading scientists, named JASON, published a report that found the current lack of interoperability among HIT data sources is a major impediment to the exchange of health information. They recommended that EHR vendors be required to develop and implement APIs that support health data architecture. The recommendation was also endorsed by the President’s Council of Advisors on Science and Technology (PCAST) in May. Requiring open APIs as a foundational standard for healthcare data would reverse the current legacy of locked systems and enable the real-time exchange of information in EHR systems to reduce costs and improve patient safety.

Continue reading “An Open Letter on Open Healthcare Data”

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Screen Shot 2014-08-21 at 11.45.17 AM“The patient is the one with the disease.”  This medical aphorism, often quoted as rule number four from Samuel Shem’s 1978 novel, The House of God, has probably been around as long as medicine itself.  Its point is that doctors need to learn to accept their own vulnerability and fallibility before they can devote themselves fully to the care of their patients.  And so long as medicine was built on the relationship between two parties, patients and doctors, the rule worked reasonably well.

More recently, however, the party is being transformed into a crowd.  A third player is increasingly encroaching on the doctor-patient relationship, and more and more doctors are beginning to suspect that it may be the vector of much of contemporary healthcare’s pathology.  Who is the third party?  Its precise identity is often difficult to pin down, but its seat in the doctor’s office and at the patient’s bedside is often occupied by a hospital, a health insurer, or a government agency.

This third party usually does not see individual patients.  Instead it sees aggregates, such as rates of mortality, disease incidence, and the utilization rates of particular tests, procedures, and pharmaceuticals.  It tends to be particularly interested in parameters such as efficiency, safety, cost, and revenue.  Because it is largely blind to individuals, however, its risk of developing certain disorders is dramatically increased.  And when it falls ill, both patients and doctors suffer.

Before patients and doctors can respond effectively to such pathologies, they must first recognize that they exist.  One of the first steps in recognizing a disorder is applying a name to it, and one physician who has taken up this challenge is Adam Ratner, MD, one of the founders of the San Antonio-based non-profit, The Patient Institute.  Ratner, who has been struggling to clarify the nature of these pathologies for many years, believes that healthcare is in the midst of an unrecognized epidemic.

Continue reading “Is the Patient the One With the Disease?”

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John Haughom MD whiteWe need to design a system of health care that optimally meets the country’s needs while also being affordable and socially acceptable. Clinicians should be at the center of this debate if care delivery is to be designed in a way that puts quality of care before financial gain.

This challenge is too important to be left to politicians and policymakers. There is an urgent need for clinicians to step up, lead the debate and design a new future for health care. Placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be an ambition for all of us. We need to find the formula that meets the needs of the patients and communities we serve. A sincere collective effort by committed clinicians to design an effective system will lead to a health care system that has a democratic mandate and the appropriate focus on optimizing the outcomes patients and society need.

As clinicians enter the debate, they should keep three things in mind.

Promote the leadership role of clinicians

We need to help politicians and policymakers recognize the role of clinical leaders in shaping a transformed but effective health care system. Clinicians must redefine the debate so that it focuses first and foremost on patients and health outcomes. Cost effective care can and should be a byproduct of optimal care. Accomplishing this will provide a strong common purpose for efforts to address the challenges of designing outcome-based funding structures and improving access to care.

Continue reading “A Time For Revolutionary Thinking”

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Screen Shot 2014-08-12 at 5.37.18 PMThe much awaited WHO ethics advisory group on the use of experimental drugs to combat Ebola has issued its statement.  While a start it is no more than a baby step.

The advisory panel did decide that they found the case for using experimental drugs in African populations ethical.  While they did not say much about why they reached this conclusion it seems valid in that when facing a deadly plague the overwhelming majority of people infected would want a drug, even one that has barely been tested, to try to save themselves or a family member.  In reaching this conclusion the committee puts to rest the argument that experimental drugs could not go to Africans at all or ought to go to Americans or Europeans first in order to avoid the charge of exploitation.  In a plague that kills 90% of its African victims complaints about unwarranted exploitative research seem a bit ridiculous even against a long history of misuse and abuse of poor desperate persons in poor African nations.

The committee did not say a good deal more other than that informed consent and choice ought to be respected.  This is far less helpful.

Continue reading “Why the WHO ethics advisory group is a start but hardly sufficient”

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Munia Mitra, MD
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Vikram Khanna
Editor-At-Large, Wellness

Joe Flower
Contributing Editor

Michael Millenson
Contributing Editor

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