Ami Parekh is the Chief Health Officer & Ankoor Shah, is VP, Clinical Excellence at Included Health. I had a long conversation with them about the philosophy of how we are doing population health and how we fix the system that we have today. I’m arguing for more primary care, but Ami restated it and says, you need somone you trust who is an expert who can help you make decisions. And this might not be a human! How do we change the system, and how does telehealth work now and how will it change? Defining health from the person perspective, not the way the health system wants to define it! Matthew Holt
Matthew Explores the Referral Process
So I thought I would try a little experiment. Following up on a recent primary care visit I got a couple of referrals. I went investigating as to what I could find out about the where to go and what the cost might be. And what the connection if any between my primary care group (One Medical), the facility & specialists I was referred to, and my health plan, Blue Shield. I hope you enjoy my little tour of this part of the online health system–Matthew Holt
Dr Kimmie Ng discusses young onset colorectal cancer
Dr Kimmie Ng discusses cancer with Dr. George Beauregard. Dr Ng heads the Young-Onset Colorectal Cancer Center, at the legendary Dana Farber Cancer Institute, and she treated George’s son who died age 32. Why are these cancers in younger people increasing so quickly? What can we do about it? What is connecting the environment, the immune system, mental health and cancer? What kind of early intervention can we advocate for? A fascinating conversation between two real leaders in this field.
How to Fix the Paradox of Primary Care
By MATTHEW HOLT
If health policy wonks believe anything it’s that primary care is a good thing. In theory we should all have strong relationships with our primary care doctors. They should navigate us around the health system and be arriving on our doorsteps like Marcus Welby MD when needed. Wonks like me believe that if you introduce such a relationship patients will receive preventative care, will get on the right meds and take them, will avoid the emergency room, and have fewer hospital admissions—as well as costing a whole lot less. That’s in large the theory behind HMOs and their latter-day descendants, value-based care and ACOs
Of course there are decent examples of primary care-based systems like the UK NHS or even Kaiser Permanente or the Alaskan Artic Slope Native Health Association. But for most Americans that is fantasy land. Instead, we have a system where primary care is the ugly stepchild. It’s being slowly throttled and picked apart. Even the wealth of Walmart couldn’t make it work.
There are at least 3 types of primary care that have emerged over recent decades. And none of them are really successful in making that “primary care as the lynchpin of population health” idea work.
The first is the primary care doctor purchased by and/or working for the big system. The point of these practices is to make sure that referrals for the expensive stuff go into the correct hospital system. For a long time those primary care doctors have been losing their employers money—Bob Kocher said $150-250k a year per doctor in the late 2000s. So why are they kept around by the bigger systems? Because the patients that they do admit to the hospital are insanely profitable. Consider this NC system which ended up suing the big hospital system Atrium because they only wanted the referrals. As you might expect the “cost saving” benefits of primary care are tough to find among those systems. (If you have time watch Eric Bricker’s video on Atrium & Troyon/Mecklenberg)
The second is urgent care. Urgent care has replaced primary care in much of America. The number of urgent care centers doubled in the last decade or so. While it has taken some pressure off emergency rooms, Urgent care has replaced primary care because it’s convenient and you can easily get appointments. But it’s not doing population health and care management. And often the urgent care centers are owned either by hospital systems that are using them to generate referrals, or private equity pirates that are trying to boost costs not control them.
Thirdly telehealth, especially attached to pharmacies, has enabled lots of people to get access to medications in a cheaper and more convenient fashion. Of course, this isn’t really complete primary care but HIMS & HERS and their many, many competitors are enabling access to common antibiotics for UTIs, contraceptive pills, and also mental health medications, as well as those boner and baldness pills.
That’s not to say that there haven’t been attempts to build new types of primary care
Continue reading…Personal and Professional Choices in PSA Testing: A Teaching Moment
By KELLI DEETER
I was intrigued by Daniel Stone’s piece on THCB in May titled “Biden’s cancer diagnosis as a teaching moment”. In my practice as a board-certified nurse practitioner, I am frequently asked about prostate specific antigen (PSA) testing by my male patients.
Nursing practice and medical practice often get blurred or lumped together. In the state of Colorado, nurse practitioners practice under their own license, and can independently diagnose and treat patients. In some settings where I have worked, I found myself frequently correcting patients who refer to me as ‘doctor’. “I am not a medical doctor, I am a nurse practitioner,” is repeated by me multiples of times per day. In this discussion of PSA testing, I want to share my decisions to order or not to order PSA testing for individuals, based on my nursing training.
It is important to refer to the guidelines for PSA testing recommended by the US Preventive Services Task Force (USPSTF), and published by the Journal of the American Medical Association (JAMA). The last updates made to the guidelines were in 2018. It is key to remember that these are guidelines, and that medical doctors, physician assistants, and nurse practitioners use these guidelines in their consideration of the patient. In nursing, a holistic and team approach with the patient’s preferences, history, cultural considerations, and desired outcome are all weighted in decision making for assessment, testing, referral, and treatment. Guidelines are just that, a GUIDE, not an absolute.
Guidelines state that for patients aged 55-69: Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction… Clinicians should not screen men who do not express a preference for screening. And for patients aged 70 and older: The USPSTF recommends against PSA-based screening for prostate cancer. This does not mean that we as providers should not test men younger than 55 or older than 70. We need to look at each patient case independently of one another and not lump everyone together.
Additionally, patients may not know how to “express a preference for screening”. It is imperative that providers have the allotted time to explore their family history of prostate and other cancers, explain to them the benefits and risks of testing, listen to and discuss their signs and symptoms, perform a digital rectal exam (DRE) if appropriate and agreed on by the patient, take into consideration their medication regimen and their age, as well as if they would want treatment or not. Certainly, if they are symptomatic, and a new medication for their symptoms is being prescribed, or if they are symptomatic and a DRE is obtained that is abnormal, a PSA should be obtained with the patient’s approval to establish a baseline, and a follow-up appointment made with repeat labs or referral, if desired by the patient. If there is a family history of prostate cancer, an early PSA screening test to establish a baseline might be preferable. Again, patient preferences must be taken into account.
People have very different feelings about western medicine and about what they want for themselves and their bodies. We must realize that just because someone has an ever increasing PSA with or without symptoms, they may not agree to a DRE or to referral to urology, surgery, or oncology. As a provider, we should obtain a refusal of recommended care. It is ok to not want testing, follow-up, or treatment, no matter one’s age. In Biden’s case, there had been no PSA testing since 2014, during his vice presidency. The fact that no reason was given is irrelevant, in 2014 he was 72 years old. Guidelines are not to test starting at age 70. The PSA level if drawn may not have aƯected his health outcome or treatment, but it may have affected the outcome of his nomination for the presidency, thus politicizing nursing and medical practice. Pointing fingers now at the past changes nothing. I agree with Stone, that this is a teaching moment: advocate for yourself as a patient, advocate for your patient as a provider, and consider that so much of one’s health is a personal choice and that it should be honored and protected.
I agree with Peter Attia’s contention in his May 24, 2024, A timely though tragic lesson on prostate cancer screening, that the PSA screening guidelines are out of date; the last revision was in 2018. Attia indicates many men remain healthy and live well past the age of 80, and aggressive cancers if caught early and treated, will better benefit the patient’s quality of life and length of life. I would also argue this is true of screening earlier in life, at age 50. Access to health care is an issue for many in our society. Marginalized populations such as the indigent, homeless, geriatric, mentally ill, and incarcerated experience greater disparities, and have a higher risk of missing any PSA testing at all. In my work as a nurse practitioner in the correctional system, for individuals entering jails and prisons this is often the first time they have ever seen a healthcare provider. These individuals often have a history of indigence, homelessness, and/or mental illness. Additionally, new cancer diagnoses are increasing and for men; 29% of new cancer types are prostate.
Age 50 is a milestone for most individuals, and they know they are supposed to get screening for colorectal cancer at this age as well as other screening tests. Consolidating care by capturing a PSA at this same time would establish an early baseline; there is never a guarantee that a patient with healthcare access issues will ever return for another appointment, due to finances, transportation, fear, or other factors. Another consideration for revising the PSA screening guidelines is lowering the threshold for PSA levels based on patient age that drive referral to urology for imaging, and putting simple language into the guidelines to look at a two-fold increase in PSA over 6-12 weeks as likely urgent referral to urology. Initiating early watchful waiting with PSA screening has the potential for saving more lives and maintaining desired qualities of life.
Kelli Deeter is a board-certified family nurse practitioner with 12 years of experience in geriatrics, rehabilitation, correction, women’s health, mental health, and complex chronic care.
Biden’s cancer diagnosis should be a teaching moment
By DANIEL STONE
Joe Biden’s metastatic cancer diagnosis brings together two controversial issues: PSA testing for prostate cancer and presidential politics. To understand what is at stake Americans need basic information about PSA testing, and a frank discussion of the reasoning behind the prostate cancer screening decisions in the former president’s case. The dribble of information we’ve gotten only creates more uncomfortable questions for Biden and his family. The absence of adequate explanation also fails to contribute to public appreciation of these important medical issues.
The prostate, a walnut-shaped gland at the base of the bladder, produces “prostate specific antigen,” or PSA. Chemically classed as a glycoprotein, a sugar/protein aggregate, it leaks from the prostate into the blood, where its level can be measured with routine blood testing.
As men age, the prostate enlarges, increasing PSA levels. Screening tests take advantage of the fact that prostate cancer usually leaks more PSA than normal prostate tissue. And in the case of prostate cancer, the PSA typically rises relatively fast.
Beyond these basic facts, the PSA story becomes hazy. Although an elevated PSA may signal cancer, most men with an elevated PSA have benign prostate enlargement, not prostate cancer. Worse yet for screening, many men with prostate cancer have a mild and slow-moving disease that requires no treatment. They coexist with their disease rather than dying of it. This fact leads to the old adage that prostate cancer is the disease of long-lived popes and Supreme Court justices.
Medical advisory panels view PSA screening with skepticism partly due to the challenges of distinguishing benign PSA elevations from those related to cancer. Confirming a suspected cancer diagnosis requires prostate biopsies that can be painful and can produce side effects. Additionally, once a diagnosis is made, patients who might have coexisted with their disease may needlessly be subject to the harms of treatment, such as radiation and surgery. Finally, the benefits of early treatment of prostate cancer have been difficult to prove in clinical studies.
For all these reasons medical advisory panels have discouraged widespread testing or recommend a nuanced approach with careful discussion of risk and benefits between patients and their
Despite these concerns, the pendulum has swung toward more PSA testing in recent years. One reason is that improvements in radiographic imaging, such as MRI, allow for “active surveillance” that can track early lesions for signs of spread, allowing doctors to distinguish between relatively benign cases of prostate cancer and those likely to progress. Interventions can then be directed more specifically to those at high risk.
In my medical practice, I have generally been an advocate for prostate cancer screening despite the controversy surrounding the clinical benefits. My experience leads me to believe that early diagnosis improves prognosis. But even without improved medical outcomes, patients and their families still benefit from early diagnosis for the purposes of planning. No one wants to be sideswiped by a late-stage symptomatic disease that limits both clinical and life choices.
Continue reading…To Beat Parkinson’s, You Must Stand on Your Head
By WOJCIECH WASILEWSKI
Dear Reader, if you’re looking for something soft and easy, please buy a different book. This one isn’t here to comfort you — it’s here to shake your lazy world, to shock you, to drag you out of the same lethargy I was trapped in for years after being diagnosed. If you feel anger, rebellion, or even a surge of motivation while reading, then it was worth writing this book, each and every hour. Parkinson’s isn’t polite — and I won’t be either. This is my war manifesto against Parkinson’s.
Throughout this book, I use the word “Parkinson” as shorthand for Parkinson’s disease, not as a reference to James Parkinson, the doctor who first described it. If that feels like an oversimplification — I apologize. But trust me, it’s the least important thing here.
People today are searching for real stories — not textbook definitions, sterile medical jargon, or sugar-coated tales of suffering. You won’t find any of that here. What you’ll find instead is something far more valuable: the truth. Raw, unfiltered, sometimes brutal, sometimes even vulgar. Why? Because that’s what this disease really is. That’s the kind of relentless fight you’ll need if you don’t want Parkinson’s to steal your life, piece by piece. I’m not afraid of that fight — and this is exactly what this book is about. I want you to stop being afraid and to believe you can get into this fight too.
This is not a scientific book. I’m not a doctor. I don’t have a PhD. I’m not an “expert” who appears on morning TV. I’m just a patient — like you. Someone who heard the diagnosis and, instead of quietly accepting it and waiting for the end, chose to fight back. And the most important part? After years of struggle, I’m living proof that it can be done. This isn’t theory — it’s my sweat, my pain, my setbacks, and my comebacks. If you want to read the story of someone who curses Parkinson’s out loud every day and refuses to let it win — you’re in the right place.
If you want to hear the voice of someone who tests every possible method to claw back one more day of normal life from this disease, someone who isn’t afraid to speak the truth and take risks — this book is for you. This is my declaration of war on Parkinson’s. And if you’re ready to join me in this fight — come on board. Because to live well with Parkinson’s, you have to completely change your lifestyle. That’s exactly what this book is about.
PARKINSON’S AFFECTS THE YOUNG
I’m talking to you — the person who typed into Google: “Parkinson’s and physical activity,” “diet and Parkinson’s,” “how to stop Parkinson’s,” “can you recover from Parkinson’s,” or “can young people get Parkinson’s.” If you’ve landed here, you’re searching for answers. I’m no miracle worker. I don’t have magic pills or secret formulas. I do have something better though — real strategies that work for me. Not just for me.
This isn’t an academic thesis. This is a battle guide. A survival manual. It’s about resisting this disease, outsmarting it, slowing it down, exhausting it. It’s about clawing back one more day of normal life — and doing it all over again tomorrow.
You know what annoys me the most? That the majority of people still think Parkinson’s is a disease of old men sitting on benches outside their apartment buildings. That’s just not true. More and more young people — people who should have their whole lives ahead of them — are being diagnosed. And then what? Fear. Panic. The crushing feeling that everything is over. Doctors rarely have time to explain what’s really going on. And the internet? It hits you with nightmare scenarios — videos of people shaking so violently they can’t even lift a spoon. Nevertheless, that’s not the full truth about Parkinson’s.
For younger people, Parkinson’s is a completely different fight — a different tempo, a different pressure, a different kind of war. They are the ones who this book is for. For people in their 30s, 40s, and 50s, with families, careers, dreams, and plans — all of which Parkinson’s is trying to rip away. We don’t have to let it happen. We can fight back.
WORDS OF CRITICISM FOR THE CRITICS
I can already hear the noise — the mocking, the scoffing, the eye-rolling. Critics saying there’s no scientific proof, that maybe something did work for me but won’t work for anyone else, that it’s all clichés and empty words. Maybe my Parkinson’s is ‘defective,’ they’ll say. Or maybe I don’t even have it. Or I just got lucky and ended up with the soft version — you know, Parkinson’s Lite.
To all the critics who will claim that nothing in this book works, I have only one thing to say: Keep on clucking.
When I first decided to fight Parkinson’s, my condition was declining fast. I had muscle rigidity. I could barely walk. My left arm didn’t swing. I felt that heavy-leg fatigue, and my tremors were intense. I passed out twice — both times collapsing in the bathroom. Then I underwent the FUS procedure, and it significantly reduced the tremor in my left hand. That was the moment I realized I had to change my life. And so began a slow but powerful transformation.
I HAVEN’T WON THE WAR
Let’s be clear, dear Reader: I haven’t won the war against Parkinson’s — not even close. Writing this book, after working full-time as an analyst for eight hours a day, takes a toll on me. Sitting at the computer for hours temporarily worsens my symptoms. Just this morning, I woke up in pain — arms, legs, back, everything.
And what did I do? First I went for a light three-kilometer run. Next I took a freezing cold shower. Then I had a healthy breakfast. These simple steps and just like that — my body came back to life.
Continue reading…Residency and Parenting Are Incompatible
By EMILY JOHNSON
Being a parent during residency requires one or more of the following:
● Family and/or friends nearby who are willing and able to provide free childcare
● A stay-at-home spouse/co-parent
● A spouse/co-parent who is willing to let their own career to be a distant second priority beneath family responsibilities and the resident’s career
● Significant amounts of generational wealth that allow you to outsource household and childcare obligations with money you didn’t personally earn
● High levels of financial risk tolerance and willingness to incur extraordinary levels of debt above and beyond average medical school debt ($234k!).
Because medical residency in the United States is incompatible with being a parent.
It is a Sunday evening, and I am writing this as I wait for my husband to get back from the hospital. He was “on call” today, which, in lay terms means his work hours were “all day.” He was out the door before I woke up, and it is now 9:30pm and Find My shows that he is still at the hospital. So that means he’s on hour 15 or 16 of his workday, and he could be leaving in a few minutes, or he could be there for another few hours (and I have no idea which).
I do know he got at least a 15-minute break today, because our toddler and I went to the hospital today to have lunch with him. Why interrupt his workday, drag a toddler across town right before nap time (thereby risking the loss of my cherished mid-day downtime because of the dreaded car nap), and pay for parking and mediocre cafeteria food on a Sunday? Because if I hadn’t, I truly don’t know when my son would have seen his dad next.
This pattern – out before the family wakes up, back after bedtime- is the rule, not the exception. An “early” day might mean he gets out before 7pm – but that doesn’t guarantee that he’ll see our toddler, who goes to bed between 7 and 7:30pm.
As a medical spouse with a young child, of the most infuriating comments I ever hear is among the lines of “but don’t they cap work hours now?” Or even worse – the occasional insinuation that perhaps today’s residents have it “too easy” because of work hour restrictions. Because the answer is yes – work hours are technically capped at 80 hours/week – but let’s talk about that:
First, here’s what an 80 hour/week schedule looks like, in case you haven’t worked one lately:
| Mon | Tues | Weds | Thurs | Friday | Sat | Sun | |
| Start | 6:45am | 6:45am | 6:45am | 6:45am | OFF(but studying for upcoming board exam) | 6:45am | 6:45am |
| End | 8pm | 6pm | 5:30pm | 8pm | 8pm | 10pm | |
| Total Hours | 13+ | 11 | 11 | 13+ | 13+ | 16 (and counting) |
Second, from a caregiving perspective, an 80/hour week cap is laughable, because you can still miss 100% of a toddler’s waking hours most days of the week on an 80 hour/week schedule.
Continue reading…Feeling the Pressure
By MIKE MAGEE
After Trump crashed the markets, citizens worldwide are “feeling the pressure.” But in the spirit of calming us down, let’s consider a story of human cooperation and success from our past.
It has been estimated that a medical student learns approximately 15,000 new words during the four years of training. One of those words is sphygmomanometer. the fancy term for a blood pressure monitor. The word is derived from the Greek σφυγμός sphygmos “pulse”, plus the scientific term manometer (from French manomètre).
While medical students are quick to memorize and learn to use the words and tools that are part of their trade, few fully appreciate the centuries-long efforts to advance incremental insights, discoveries, and engineering feats that go into these discoveries.
Most students are familiar with the name William Harvey. Without modern tools, he deduced from inference rather than direct observation that blood was pumped by a four chamber heart through a “double circulation system” directed first to the lungs and back via a “closed system” and then out again to the brain and bodily organs. In 1628, he published all of the above in an epic volume, De Motu Cordis.
Far fewer know much about Stephen Hales, who in 1733, at the age of 56, is credited with discovering the concept of “blood pressure.” A century later, the German physiologist, Johannes Müller, boldly proclaimed that Hales “discovery of the blood pressure was more important than the (Harvey) discovery of blood.”
Modern day cardiologists seem to agree.
Continue reading…Emory, Balloon Angioplasty, and the Musk Attack on Medical Diplomacy
By MIKE MAGEE
“The recently announced limitation from the NIH on grants is an example that will significantly reduce essential funding for research at Emory.”
Gregory L. Fenes, President, Emory University
In 1900, the U.S. life expectancy was 47 years. Between maternal deaths in child birth and infectious disease, it is no wonder that cardiovascular disease (barely understood at the time) was an afterthought. But by 1930, as life expectancy approached 60 years, Americans stood up and took notice. They were dropping dead on softball fields of heart attacks.
Remarkably, despite scientific advances, nearly 1 million Americans ( 931,578) died of heart disease in 2024. That is 28% of the 3,279,857 deaths last year.
The main cause of a heart attack, as every high school student knows today, is blockage of one or more of the three main coronary arteries – each 5 to 10 centimeters long and four millimeters wide. But at the turn of the century, experts didn’t have a clue. When James Herrick first suggested blockage of the coronaries as a cause of heart seizures in 1912, the suggestion was met with disbelief. Seven years later, in 1919, the clinical findings for “myocardial infarction” were associated with ECG abnormalities for the first time.
Scientists for some time had been aware of the anatomy of the human heart, but it wasn’t until 1929 that they actually were able to see it in action. That was when a 24-year old German medical intern in training named Werner Forssmann came up with the idea of threading a ureteral catheter through a vein in the arm into his heart.
His superiors refused permission for the experiment. But with junior accomplices, including an enamored nurse, and a radiologist in training, he secretly catheterized his own heart and injected dye revealing for the first time a live 4-chamber heart. Two decades would pass before Werner Forssmann’s “reckless action” was rewarded with the 1956 Nobel Prize in Medicine. But another two years would pass before the dynamic Mason Sones, Cleveland Clinic’s director of cardiovascular disease, successfully (if inadvertently) imaged the coronary arteries themselves without inducing a heart attack in his 26-year old patient with rheumatic heart disease.
But it was the American head of all Allied Forces in World War II, turned President of the United States, Dwight D.Eisenhower, who arguably had the greatest impact on the world focus on this “public enemy #1.” His seven heart attacks, in full public view, have been credited with increasing public awareness of the condition which finally claimed his life in1969.
Cardiac catheterization soon became a relatively standard affair. Not surprisingly, less than a decade later, on September 16, 1977, an East German physician, Andreas Gruntzig performed the first ballon angioplasty, but not without a bit of drama.
Dr. Gruntzig had moved to Zurich, Switzerland in pursuit of this new, non-invasive technique for opening blocked arteries. But first, he had to manufacture his own catheters. He tested them out on dogs in 1976, and excitedly shared his positive results in November that year at the 49th Scientific Session of the American Heart Association in Miami Beach.
He returned to Zurich that year expecting swift approval to perform the procedure on a human candidate. But a year later, the Switzerland Board had still not given him a green light to use his newly improved double lumen catheter. Instead he had been invited by Dr. Richard Myler at the San Francisco Heart Institute to perform the first ever balloon coronary artery angioplasty on an awake patient.
Gruntzig arrived in May, 1977, with equipment in hand. He was able to successfully dilate the arteries of several anesthetized patients who were undergoing open heart coronary bypass surgery. But sadly, after two weeks on hold there, no appropriate candidates had emerged for a minimally invasive balloon angioplasty in a non-anesthetized heart attack patient.
In the meantime, a 38-year-old insurance salesman, Adolf Bachmann, with severe coronary artery stenosis, angina, and ECG changes had surfaced in Zurich. With verbal assurances that he might proceed, Gruntzig returned again to Zurich. The landmark procedure at Zurich University Hospital went off without a hitch, and the rest is history.
Continue reading…
