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Christina Liu

The Art and Soul of Medicine Exist in the Ordinary

By HANS DUVEFELT

The Art of Medicine is Doing the Ordinary Well

Primary care doctors don’t usually operate any sophisticated medical instruments or perform any advanced procedures. But there is still art in what we do. We take care of ordinary ailments in ordinary people and that can be done well or not so well. There is no obvious glamor in it, but when our prescriptions, basic procedures or simple advice help people feel better, we live up to our own and our patients’ hopes and expectations – and some of the time, we even exceed them.

Art is art, regardless of the medium or subject. Weren’t the old Dutch masters’ most appreciated paintings depictions of ordinary people in ordinary circumstances? Not every artist gets to paint the Sistine Chapel.

So many things in our culture are at the two extremes of poorly done and exquisite: fast fashion or haute couture, drive-up burgers or five star restaurants. Fewer things are made with care by craftspeople for individual users. Medicine needs to be more like that in order to bring real healing in many conditions.

In our everyday encounters with our patients, we are often distracted by things other than what they expect or hope to get from us. We have agendas imposed on us for preventive care and public health purposes. It is sometimes hard to do your best if you can’t concentrate on the issue at hand. Art requires focus. It is not a casual endeavor. It requires attention to detail, just as much as a vision of the big idea. It is – or should be – for each of us, in order to do our best, to find the balance between those two aspects of our work.

The Soul of Medicine is Connecting as Humans

We are not technicians. We treat the whole person, because most things in primary care are diseases that affect more than just one organ. We now also, again (historically), accept that diseases of the body may have their root causes in what we call the soul. In order to know and treat another person, we must show our own. Only if we do that will we learn enough to be of any real help to the patient who hopes to trust us enough to take our advice. We must create connection.

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Make Mine Bioresorbable

By KIM BELLARD

I learned a new word this week: bioresorbable.  It means pretty much what you might infer — materials that can be broken down and absorbed into the body, i.e., biodegradable.  It is not, as it turns out, a new concept for health care – physicians have been using bioresorbable stitches and even stents for several years.  But there are some new developments that further illustrate the potential of bioresorbable materials. 

It’s enough to make Green New Deal supporters smile.

Bioresorbable stents and stitches are all well and good – who wants to be stuck with them or, worse yet, to need them removed? – but they are essentially passive tools.  Not so with pacemakers, which have to monitor and respond.  Medicine has made great progress in making pacemakers ever smaller and longer lasting, but now we have a bioresorabable pacemaker. 

Researchers from Northwestern University and The George Washington University just published their success with “fully implantable and bioresorbable cardiac pacemakers without leads or batteries.”  What their title might lack in pithy is more than offset by the scope of what they’ve done.  Fully implantable!  No leads!  No batteries!  And bioresorbable! 

Most pacemakers are, of course, designed to be permanent, but there are situations where they are implanted on a temporary basis, such as after a heart attack or drug overdose.  Dr. Rishi Arora, co-leader of the study, noted: “The current standard of care involves inserting a wire, which stays in place for three to seven days. These have potential to become infected or dislodged.” 

Dr. Arora went on to explain:

Instead of using wires that can get infected and dislodged, we can implant this leadless biocompatible pacemaker. The circuitry is implanted directly on the surface of the heart, and we can activate it remotely. Over a period of weeks, this new type of pacemaker ‘dissolves’ or degrades on its own, thereby avoiding the need for physical removal of the pacemaker electrodes. This is potentially a major victory for post-operative patients.

The device is only 15 millimeters long, 250 microns thick and weighs less than a gram, yet still manages to deliver electric pulses to the heart as needed.  It is powered and controlled using near field communications (NFC); “You know when you try to charge a phone wirelessly? It’s exactly the same principle,” GW’s Igor Efimov, a co-leader of the study, told StatNews. 

It dissolves over a period of days or weeks, based on the specific composition and thickness of the materials.

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The Science of Clinical Intuition

By HANS DUVEFELT

In 2002, Dr. Trisha Greenhalgh published a piece in the British Journal of General Practice titled Intuition and Evidence – Uneasy Bedfellows? In it she writes eloquently about the things Christer Petersson and I have written articles on and emailed each other about. He mentioned her name and also Italian philosopher Lisa Bortolotti, and I got down to some serious reading. These two remarkable thinkers have described very eloquently how clinical intuition actually works and describe it as an advanced, instantaneous form of pattern recognition.

Clinical Intuition (should we start calling this CI, as opposed to the other, electronic form of pattern recognition, AI – Artificial Intelligence?) begins with clinical patient experience but is cultivated through reflection, writing and dialogue with other physicians. And as Petersson and I have both written, there isn’t enough of the latter in medicine today. Both of us do as much reflecting and writing as we can, but we both know that more collegial interchange can make all of us better clinicians. Greenhalgh writes:

The educational research literature suggests that we can improve our intuitive powers through systematic critical reflection about intuitive judgements–for example, through creative writing and dialogue with professional colleagues. It is time to revive and celebrate clinical storytelling as a method for professional education and development. The stage is surely set for a new, improved–and, indeed, evidence-based–‘Balint’group.
— Read on www.ncbi.nlm.nih.gov/pmc/articles/PMC1314297/

Bortolotti, the philosopher, makes the case that experts are more intuitive than novices, a skill that only comes with experience, and have developed advanced pattern recognition abilities that allow them to make decisions faster than possible when only using analysis and reasoning. Her article is quote-heavy. She writes:

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Why I Seldom Recommend Vitamins or Supplements

By HANS DUVEFELT

People here in northern Maine, as in my native Sweden, don’t get a whole lot of natural sunlight a good part of the year. As a kid, I had to swallow a daily spoonful of cod liver oil to get the extra vitamin D my mother and many others believed we all needed. Some years later, that fell out of fashion as it turned out that too much vitamin A, also found in that particular dubious marine delicacy, could be harmful.

This is how it goes in medicine: Things that sound like a good idea often turn out to be not so good, or even downright bad for you.

Other vitamins, like B12, can also cause harm: Excess vitamin B12 can cause nerve damage, just as deficiency can.

Both B12 and D can be measured with simple blood tests, but the insurance industry doesn’t pay for screening. That is because it hasn’t been proven that testing asymptomatic people brings any benefit. In the case of B12, it is well established that deficiency can cause anemia and neuropathy, for example. But here is no clear evidence what the consequences are of vitamin D “deficiency”. A statistically abnormal result is not yet known to definitely cause a disease or clinical risk, in spite of all the research so far, but we’re staying tuned.

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#Healthin2Point00, Episode 220 | Olive’s massive raise, Ro buys Kit, plus funding for Tendo & SWORD

Today on Health in 2 Point 00, I’m cheering England’s win against Germany this week – but Jess keeps us on track with health tech deals. Olive gets another $400 million, bringing their total up to $902 million – with $802 million of that since March 2020. Tendo Systems gets $50 million in a Series A, working on communication between providers and consumers. General Catalyst strikes again, this time in a round with SWORD Health raising $85 million in a Series C, bringing their total to $135 million. This is an MSK company, with a lot of good investors here. Finally, Ro buys Kit an at-home testing company – how does Hims stack up now? And, in case you missed it, Sharecare hits the NYSE today – get the scoop from Jess’s interview with their CEO yesterday. –Matthew Holt

Go Ahead, AI—Surprise Us

By KIM BELLARD

Last week I was on a fun podcast with a bunch of people who were, as usual, smarter than me, and, in particular, more knowledgeable about one of my favorite topics – artificial intelligence (A.I.), particularly for healthcare.  With the WHO releasing its “first global report” on A.I. — Ethics & Governance of Artificial Intelligence for Health – and with no shortage of other experts weighing in recently, it seemed like a good time to revisit the topic. 

My prediction: it’s not going to work out quite like we expect, and it probably shouldn’t. 

“Like all new technology, artificial intelligence holds enormous potential for improving the health of millions of people around the world, but like all technology it can also be misused and cause harm,” Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said in a statement.  He’s right on both counts.

WHO’s proposed six principles are:

  • Protecting human autonomy
  • Promoting human well-being and safety and the public interest
  • Ensuring transparency, explainability and intelligibility 
  • Fostering responsibility and accountability
  • Ensuring inclusiveness and equity 
  • Promoting AI that is responsive and sustainable

All valid points, but, as we’re already learning, easier to propose than to ensure.  Just ask Timnit Gebru.  When it comes to using new technologies, we’re not so good about thinking through their implications, much less ensuring that everyone benefits.  We’re more of a “let the genie out of the bottle and see what happens” kind of species, and I hope our future AI overlords don’t laugh too much about that. 

As Stacey Higginbotham asks in IEEE Spectrum, “how do we know if a new technology is serving a greater good or policy goal, or merely boosting a company’s profit margins?…we have no idea how to make it work for society’s goals, rather than a company’s, or an individual’s.”   She further notes that “we haven’t even established what those benefits should be.”

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Sharecare ($SHCR) Hits NASDAQ Tomorrow, CEO Jeff Arnold on Closing the SPAC IPO

By JESSICA DaMASSA, WTF HEALTH

Sharecare ($SHCR) starts trading on the NASDAQ tomorrow and CEO Jeff Arnold has come back to catch us up on what’s happened since April when we first spoke and took a deep-dive into Sharecare’s population-health-slash-care-navigator-slash-health-security business model. That interview (watch here: https://youtu.be/P6DzFbtiLWg) digs into the $400 million/year revenue model Jeff’s built so far, and now THIS CHAT picks up where we left off — mere hours before Sharecare heads into the public market. valued at just under $4 billion dollars, with ZERO Debt and $400 million in cash to invest in scaling up.

Turns out a lot can happen while you’re waiting for your paperwork to be signed! So what’s new? How about the $50 million dollar private placement Anthem has made into business? Jeff explains how this kind of backing from the country’s second largest health insurance company is not only a win when it comes to securing a customer base, but also how it will likely impact product roadmap. The Anthem investment was closely linked to Sharecare’s January acquisition of health tech startup Doc.AI, which had been working with Anthem on some very payer-friendly tools that will likely be expanded. And speaking of expansion? Jeff’s already made more than a dozen acquisitions to build up Sharecare’s three main verticals over the years– what else could they possibly need now? Tune in for all the last-minute news and numbers before $SHCR pops tomorrow!

Did Glen Tullman Just Launch Another New Category? Transcarent the ‘Health Experience Company’

By JESSICA DaMASSA, WTF HEALTH

For those keeping score at home, Glen Tullman is scaling up Transcarent faster than he did Livongo. The startup just closed a $58M Series B, bringing its total funding just shy of $100M. In less than 8 months. What’s the hurry? Have we ordered the balloons for the IPO yet? Glen says he’s out to fix the core problem first, and, in this interview, we get into the details about what that problem statement is all about and you might be surprised.

This is more of a payment model story than anyone may have all initially realized. And, while we may keep trying to put Transcarent into the “healthcare navigator” box or call it a “second opinion service” or a “centers of excellence play,” the truth is that those are all means to achieve a much larger end, which is about redefining the healthcare experience and its payment model for self-insured employers. Remember when Livongo created its own category of care (applied health signals) because they didn’t fit in with what a ‘chronic condition management’ company meant to the market? Well, I think Glen just used this interview to soft-launch a new category of healthcare company here again with Transcarent…

“People always try to put us in a category,” says Glen. “Are you a navigator? No, we’re not a navigator. We do navigation. Are you a health management company? No, we’re not. Are you a supplier? No, we’re not. Are you a PBM? No, we’re not. But we do all of those things to create an experience and that’s why, when you think about it, we’re a health experience company and that’s a new category that no one has.”

I get Glen to talk specifics about what this really means — directly managing healthcare spend for employers in a ‘category-creating’ completely at-risk way – and the examples really do help bring it to life. So does hearing about how he sees Transcarent as completely different than Accolade or Grand Rounds, which are often listed as competitors.

What other trouble do we get into in this 30-minute mega chat? OF COURSE I get his take on this year’s record-breaking investment into health tech, whether or not he thinks we’re in a bubble, and how Amazon, Walmart, and other non-traditional players are going to impact healthcare moving forward. Lots of insights in this one!

Health Tech: Part II –Powering Up The Vision

By MIKE MAGEE

Few can disagree that, in the fog of the Covid 19 pandemic, health technology entrepreneurs have been on a tear. In the first year of Covid’s isolation induced new reality, digital health companies experienced a $21.6 billion investment boost, double that of the prior year, and four times 2016 funding.

By year two, the investment community exhibited some signs of self-restraint by raising a few open ended questions. For example, in early 2021, Deloitte & Touche led a Future of Health panel at the J.P. Morgan Healthcare conference, reporting that “panelists suggested that entrepreneurs need to go beyond products that simply improve processes or solve existing problems.”

Panelists predicted that virtual health delivery services will expand; consumers will demand greater involvement including expansion of  home diagnostics; and investment driven mergers and acquistions will explode – all of which has proven to be true.

Adding push to shove, Deloitte added this final nudge: “Entrepreneurs who define new markets, dominate them with a strategy people can understand, and extract value will likely be the most successful.”

Forty years ago, in the early beginnings of Health Tech, words similar to those above triggered cautionary tones from traditionalists. For example,  Dr. John A. Benson, Jr., then President of the Board of Internal Medicine, stated “There is a groundswell in American medicine, this desire to encourage more ethical and humanistic concerns in physicians. After the technological progress that medicine made in the 60’s and 70’s, this is a swing of the pendulum back to the fact that we are doctors, and that we can do a lot better than we are doing now.”

He accurately described the mood then, and for most of the 20th century, of academic clinicians toward technology, a complex love-hate relationship that has rejoiced and cheered on progress, while struggling to accept and master change in a manner that would avoid driving a wedge between academicians, clinicians and patients.

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