Last year, we soundly criticized the American Heart Association (AHA) on this blog for its proposal to lower the thresholds for treating cholesterol and getting larger numbers of Americans to swallow statins. We also exposed wellness vendor StayWell, for its mathematically impossible claims of success in British Petroleum’s wellness program. Proving that great minds aren’t the only ones that think alike, StayWell and the AHA have now joined forces. Specifically, the AHA invited the CEO of StayWell, Paul Terry, Ph.D., to help write its workplace wellness policy statement, sort of like Enron inviting Bernie Madoff to help design its financial plan. You don’t learn of this fox-in-the-henhouse conflict of interest unless you read the table on the penultimate page of text.
Naturally, Mr. Terry parlayed this windfall to StayWell’s advantage. The statement: “currently available studies indicate that employers can achieve a positive ROI through wellness” is footnoted to two studies authored by: Paul Terry, along with other Staywell executives. One wonders how a StayWell executive writing policy for the AHA based partly on StayWell’s own articles passes the AHA’s own test of “making every effort to avoid actual or potential conflicts of interest that may arise as a result of an outside relationship.”
How did this conflict of interest get by the peer reviewers? Look at the list of peer reviewers. Prominent among them is Ron Goetzel. Readers of THCB may recall Mr. Goetzel not just from his central role in the Penn State debacle, but also from the ”The Strange Case of the C. Everett Koop Award,” in which it was documented that his committee gave the ironically named award to a sponsor of the award (without disclosing that conflict), even though that sponsor had admitted lying about saving the lives of 514 cancer victims, who, as luck would have it, didn’t have cancer. (The sponsor, Health Fitness Corporation, a division of the equally ironically named Trustmark, has won the Koop award several times, thus proving the cost-effectiveness of their sponsorship.)
If this litany were not enough to dismiss the policy statement forthwith, there is small matter of the actual policy itself, a full employment act for wellness vendors and cardiologists alike, advocating more screening of more employees more often, while ignoring more self-evident facts than Sergeant Schultz. Specifically, they cherry-picked the available literature, continuing to cite the old “Harvard study” whose lead author has now walked it back three times. Except that they didn’t call it the “old Harvard study,” but rather a “recent [italics ours] meta-analysis,” despite the fact it was submitted for publication in 2009, and the average year of the analyses in the study was 2004. Some studies began in the 1990s and were able to use sleight-of-hand to “show savings” despite presumably — in accordance with the conventional wisdom of the era — getting people to eat more carbohydrates and less fat. No wonder Soeren Mattke of RAND Corporation dismissed the Harvard data as archaic in his interview with CoHealth radio in February 2014.
Continue reading “Circulation: The Nineties Called. They Want Their Wellness Policy Back”
Filed Under: THCB
Tagged: American Heart Association, Circulation, Rand, Ron Goetzel, Screening, Wellness, Workplace Wellness
Jul 15, 2014
Recently published statistics show that the top-grossing medication in the U.S. for 2013 was the antipsychotic Abilify (aripiprazole) with over $6 billion in sales, narrowly beating out the previous few years’ winner, Nexium.
The past decade’s dominating pharmaceuticals have been Lipitor (atorvastatin) for high cholesterol and Nexium (esomeprazole) for acid reflux. Nexium was preceded at the top by Prilosec (omeprazole), and before that we had Pepcid (famotidine) and Zantac (ranitidine) somewhere near the top of the sales data.
A country’s medicine cabinets tell us something about its culture and its predominant issues.
From the late 1960′s to the early 1980′s the tranquilizer Valium (diazepam) was the top grossing drug. The 1965 US sales volume of tranquilizers was somewhere around 166 million prescriptions or 14% of all prescriptions filled in this country. Both “uppers” and “downers” were subjects of the 1966 best seller “Valley of the Dolls”. Valium rose to the top after the previous few years’ blockbuster tranquilizer Miltown (meprobamate) proved to have significant toxicity risks.
So, this country has gone from treating nervousness and suppressed emotions to heartburn and high cholesterol, the latter two sometimes self-inflicted through dietary indiscretion, and now back to psychiatric conditions like schizophrenia. True, there are other, “softer” indications for Abilify – bipolar disorder, treatment resistant depression and for chemical restraining of aggressive individuals, even children.
One cannot help but stop and reflect on this pharmaceutical sales phenomenon.
The postwar years, although portrayed in media as a time of health care advances, optimism and prosperity, were years of great anxiety. My own observation is that many of my patients and acquaintances who were children during World War II lack the emotional imperturbability of those whose childhood fell in the 1930′s, born in the early to mid 1920’s.
Continue reading “What’s In Our Medicine Cabinets?”
Filed Under: THCB
Tagged: Abilify, Drug sales, Medicalization, Nexium, Pharmaceutical sales, Viagra, Wellness
Jun 20, 2014
Rube Goldberg was an American cartoonist and inventor, perhaps best known for the extremely complicated contraptions he devised for performing the simplest tasks. Each year, a national Rube Goldberg Machine Contest is held, challenging competitors to devise bizarre contrivances that can shine a shoe or zip a zipper. One day while watching a group of children marvel at such a machine in a museum, a thought occurred to one of us: As healthcare becomes more complex, the interactions between patients, physicians, hospitals, payers, and communities increasingly resemble a Rube Goldberg machine.
Consider a recent case. Ms. Jones was a 50-something year old African American woman with type I diabetes, high blood pressure and end-stage kidney disease requiring peritoneal dialysis, a form of dialysis performed nightly at home. She was recently admitted to the hospital because of an apartment fire that destroyed everything she owned, including her home dialysis equipment and medications. Once she was hospitalized, the medical team restarted her dialysis, restored her blood chemistries to normal, corrected her blood sugar, and began to make plans for her discharge. There was just one problem. They had no place to send her.
Ms. Jones could not return to her apartment, which had essentially burnt to the ground. She did not qualify for admission to a nursing home. And she couldn’t afford to rent a new apartment, at a cost of about $1,500 per month. She had paid for insurance on the apartment for years, but had recently let the insurance lapse to help finance the purchase of an $8,000 living room suite. The medical team had heard that social service agencies would provide one month’s rent, but it turned out that she could get only one-time distributions of $100 from the Red Cross and $200 from the Salvation Army – not nearly enough.
As the days rolled by, the medical team caring for Ms. Jones began feeling escalating pressure from hospital administration to discharge her. Her medical problems had been taken care of, and there was no medical need for her to remain in a hospital bed at a cost of $1,500 per day. The team arranged to get her dialysis supplies delivered to her sister’s house, hoping that she could stay there until she found a place of her own. But it turned out that too many people were already living there. Attempts to find temporary housing through friends and her church dead-ended. Hotels she contacted were all too expensive. Going to a homeless shelter was not a viable option; it would give her a place to sleep, but she couldn’t perform her dialysis there. She volunteered that she could live out of her car, for which she reportedly used some of the $300 to buy gas, but it later turned out that she did not have one.
As pressure to discharge Ms. Jones mounted, team members became increasingly frustrated. Each new hope was thwarted by an opposing reality. The team had provided their patient with the best available medical care, marshaling the impressive resources of a major academic medical center to solve her acute medical problems as effectively and efficiently as possible. But now they had run up against a barrier for which they lacked the necessary training and resources – not a medical problem so much as a social one. Treating acute illness was doable, but looking out for their patient as a whole person with a real life outside the hospital was proving quite another matter.
Continue reading “Health Care’s Rube Goldberg Machine. Who Is Responsible?”
Filed Under: OP-ED, THCB
Tagged: Blame, Gunderman, Health Care Costs, Health care system, Rube Goldberg, Wellness
Jun 12, 2014
Hospitals are environments where emotions can run high. These emotions cross all boundaries and can affect physicians, hospital staff, patients and their families. Dealing with an “angry” patient is a common challenge that physicians face.
The first step for a physician encountering an angry patient is to remain calm and allow the patient to express his or her concerns. In my experience, “angry” patients can be viewed as falling into several different categories. By understanding and thinking about these categories, physicians can begin to identify the root of the anger and take measures to address it. This exercise might seem simplistic at first. However, you’ll be amazed by how powerful the results can be.
Why do patients become angry? What are the common “root” causes?
Medical illness is often accompanied by pain, so much so that pain is often considered the fifth vital sign. Assessment and treatment of pain is an important factor for all medically ill patients. Anger is a common emotion in patients with pain, especially chronic pain. It is thought that the presence of significant anger may in fact further aggravate the feeling of pain. Physicians must not only be able to assess pain, but also to weigh the benefits and the risks in prescribing analgesics. When any patient appears to be “angry,” the presence of pain, especially untreated/undertreated pain, must be considered and rectified as a matter of urgency.
2. Fear and worry
Being medically ill, especially if one is hospitalized, can be an intensely destabilizing experience for both the patient and his or her caregivers. In some cases, an unknown prognosis, the occurrence of complications or the impact of the illness on their independence, can make patients fearful about the future. This worry can manifest as anger, and since patients cannot direct their worry or anger toward their illness, this anger may be displaced onto people around them, including hospital workers. Attempting to recognize, and where possible alleviate, their worries is often very helpful.
3. Feeling unheard or uninvolved
Any patient who displays anger in a hospital setting is guaranteed to attract attention. For some patients the expression of anger may actually suggest that they feel “unheard” in the medical setting. They may feel that they do not have enough information about their condition or their concerns have not been addressed. The question then arises, how do we make them feel heard? Do they understand why they are in the hospital? Do they understand what their treatment options are? Do they feel they have been part of the decision-making process? Ensuring that patients feel they are involved in their care can reduce the anger that can arise out of being “unheard” in a hospital.
Continue reading “The Angry Patient: A Primer For Physicians.”
Filed Under: THCB
Tagged: Anger, Doctor Management, doctor/ patient relationship, Pain Management, Wellness
Jun 12, 2014
Consider that for the last year or so, we have been treated a deluge of entreaties to reduce our salt intake, with the American Heart Association going so far as to claim that daily sodium intake should not exceed 1,500 mg. This puts it at odds with the Institute of Medicine, and now European researchers whose data indicates that the healthy range for sodium intake appears to be much higher.
Our conversation about sodium, much like advice about purportedly evil saturated fats and supposedly beneficial polyunsaturated fats, exemplifies a national obsession with believing eating more or less of a one or a small number of nutrients is the path to nutritional nirvana.
A few weeks back, an international team of scientists did their level best to feed this sensationalistic beast by producing what’s become known since then as the meat-and-cheese study, because it damned consumption of animal proteins.
Continue reading “Cheeseburger Please, and Make It a Double”
Filed Under: THCB
Tagged: animal-protein vs. plant-protein, Cancer, Diabetes, L-Nutra, Meat and Cheese Study, Obesity, Population Health, Vik Khanna, Wellness
May 14, 2014
In further celebration of Nurses Week, it’s worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.
The point I’m raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what’s right for patients.
We’ve seen recently that American healthcare spending is UP about 10%(the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That’s a noble goal.
From the TIME article, an opinion piece written by a nurse from California:
“… I worry that the switch may compromise the quality of the care our patients receive.”
The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.
In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren’t equal. Not every patient is the same.
Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.
Continue reading “Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care.”
Filed Under: OP-ED, THCB
Tagged: Burnout, frontline health workers, LEAN, Mark Graban, Nurses, Quality, The ACA, Wellness
May 8, 2014
My wife calls them “hand-me-ups”… things we inherit from our kids. My ex-fashionable shirt that my son wore in college.Our semi-vegetarian diet my daughter adopted in high school. The dog at my feet that came visiting for the weekend, three years ago.
Our lives are enhanced and modified by the most unexpected of teachers, our children. The mentoring of our progeny keeps those of graying years at least partially youthful. Still, I was astonished to hear this week, the words, “Dad, you need to starting doing drugs.”
The “dad” being addressed is 93 years old and has advancing cancer. He is tired, nauseas, anxious and sleeps poorly. Though he likely has a number of months to live, he has become withdrawn. Despite my usual medical brew, his incapacitating symptoms are without palliation.
Dad is miserable. Enter his daughter with the solution. The “drug” she is talking about is the treatment de jour, marijuana.
How did this happen? We raise our kids to be good, honest, mature citizens; we drive them to soccer, suffer through years of homework (do you remember dioramas?), and do the whole college obsessive-compulsive tour thing. In addition, above all, we beg our offspring to stay away from pot, pills and addictive mind-altering potions.
Now they turn on us, pushing ganja in our time of need. How did we go wrong? Actually, it is we that missed a great opportunity.
50% of Americans have inhaled marijuana at some point in their lives. More than 25 million of our neighbors have used it within the last year. Those that imbibe are of a decidedly younger demographic. The oldest citizens, especially those of the Greatest Generation, are much less likely to have experience with cannabis.
Fortunately, once again, youth presents the solution.
Continue reading “Dad, You Have to Inhale”
Filed Under: Uncategorized
Tagged: Cancer, James Salwitz, Marijuana, marijuana legalization, Patients, Wellness
May 6, 2014
On Tuesday of this week (4/29/14), I was on the Katie Couric Show to discuss Integrative Medicine.
Somewhat ironically, I returned from Manhattan that same day to a waiting email from a colleague, forwarding me a rather excoriating critique of integrative medicine on The Health Care Blog, and asking me for my opinion.
The juxtaposition, it turns out, was something other than happenstance. The Cleveland Clinic has recently introduced the use of herbal medicines as an option for its patients, generating considerable media attention.
Some of it, as in the case of the Katie Couric Show, is of the kinder, gentler variety. Some, like The Health Care Blog — is rather less so. Which is the right response?
One might argue, from the perspective of evidence based medicine, that harsh treatment is warranted for everything operating under the banner of “alternative” medicine, or any of the nomenclature alternative to “alternative” – such as complementary, holistic, traditional, or integrative.
One might argue, conversely, for a warm embrace from the perspective of patient-centered care, in which patient preference is a primary driver.
I tend to argue both ways, and land in the middle. I’ll elaborate.
Continue reading “A Holistic View of Evidence-Based Medicine”
Filed Under: OP-ED, THCB, The Vault
Tagged: CAM, David Katz, Evidence Based Medicine, Integrative Medicine, prevention, Wellness
May 2, 2014
Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor. Aunt Tillie suggested that he try to work under a different supervisor. Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed. Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines. So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”
Tillie replied, “I blame our educational system for that.”
Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress. To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”
SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.
Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress? It would seem like mathematically that would have to be the case. However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox. Hence Keas’ selfless reasons for publishing this poll: All employees being either average or above average in the stress department means we have a major stress epidemic on our hands. This perhaps explains why Keas is “bringing attention to these findings.”
In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms: All of us want our children to be normal but who amongst us wants their children to be average?
Continue reading “Keas Poll on Workplace Stress and Disease Burden Provides an Education”
Filed Under: THCB
Tagged: Al Lewis, Hypertension, Keas, Obesity, productivity, stress, Vik Khanna, Wellness, Workplace, Workplace Wellness
May 2, 2014
After my last post about “the gift of cancer” I must say that CLL has felt much less like a gift this month.
Joining the ranks of those with “a diagnosis” has given me a some insight into what our patients face all the time.
Recently, I received my second dose of humility. I capped off a truly exhausting week in the hospital with a routine lab follow-up.
The last day of my 85-hour week I had my CBC checked, and my platelets dropped from the 100s to the 30s.
My first reaction was denial. Lab error.
Unfortunately, they dropped further the next day and I realized that the little red bumps on my legs weren’t some skin reaction, but petechiae. Bummer. Turns out that in addition to the 2% of people diagnosed with CLL under age 40, I also joined the 20% who develop idiopathic thrombocytopenic purpura (ITP).
The treatment of choice for ITP is prednisone 1mg/kg. So after a visit with my oncologist, I started 80mg of prednisone.
I realized with more than a little chagrin that I have a double standard about therapeutics. I was surprised at how much I despise being on prednisone.
I had never taken it before, and I would guess that I prescribe it every week, if not every day, that I work in the hospital. I have always felt that prednisone is fine for my patients to take.
Steroids work to help clear up that asthma flare, quickly improve that gout pain, or even help with a burst of energy in the last days or weeks of life for a terminal patient.
But for me? No thank you.
Continue reading “The Gift of Cancer”
Filed Under: Physicians, THCB, The Vault
Tagged: Brett Hendel-Paterson, Cancer, leukemia, Oncology, Physicians, Wellness
Apr 30, 2014