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Tag: public health

The Perils of Multitasking

The dangers of texting while driving recently received renewed attention thanks to a public service video produced by German film director Werner Herzog.  The National Highway Traffic Safety Administration estimates that driver distraction results in approximately 3,000 deaths per year, as well as an additional 400,000 injuries.  Experts have estimated that the risk of a crash may increase by more than 20 times when texting, exceeding the risk associated with intoxication.

Texting while driving is just one example of a larger phenomenon of our age, often referred to as multitasking.  The term was coined by IBM engineers in the 1960s to refer to the ability of a microprocessor to perform multiple tasks at once.  Today the term is more often applied to human beings attempting to do more than one thing, such as simultaneously watching television and folding laundry, or answering emails while talking on the phone.  Many health professionals pride themselves on their multitasking.

In fact, however, the term multitasking is a bit of a misnomer, even in the domain of computing.  At least where one microprocessor is concerned, a computer does not so much multitask as it switches back and forth between tasks at such a high rate of speed that it appears to be doing multiple things at once.  Only more recently, with the advent of multicore processing, has it become possible for computers genuinely to multitask.

The same thing applies to human beings.  Health professionals and others who think they are multitasking are typically switching back and forth between different tasks over short periods of time.  And in most cases, multitaskers are not able to perform any of the activities in which they are engaged as well as they could if they concentrated on them one at a time.  It takes time and effort to re-focus on each task at hand, and this tends to degrade the effectiveness and efficiency of each.

To be sure, multitasking is not impossible.  In one sense, simply remaining alive requires us to multitask all the time.  Our hearts are continuously pumping, lungs exchanging gases, kidneys filtering the blood, immune system fighting infections, and all the while we are also digesting our last meal.  Add to this the ceaseless multitasking of the brain, which is monitoring the environment and maintaining our posture while simultaneously walking and chewing gum, and the complexity multiples.

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Could Mobile Health Become Addictive?

The hype over mobile health is deafening on most days and downright annoying on some.  So it is with some reluctance that I admit that mobile has the potential to be a game-changer in health.  I’ve professed enthusiasm before, but that was largely around the use of wireless sensors to measure physiologic signals and SMS text as a way to deliver messages to patients and consumers.  For several years, the industry has been awash with smartphone apps (by a recent count more than 40,000).  At the Center for Connected Health, we started looking at mobile health as far back as 2008 and could not justify the excitement around smart phones and apps at that time, mostly because our patient population did not demonstrate significant enough adoption of smartphones to justify development in this area.

I felt very unpopular at all of the major conferences.  I talked about our success with text messaging as a tool for engaging pregnant teens in their prenatal care and helping patients battling addiction to stick with their care plan, while others were touting the virtues of their various apps.

It’s worth noting that our primary focus at the Center for Connected Health has been patients with chronic illness.  As such, we are every bit as concerned about the 85 year old with congestive heart failure as we are about the young professional with hypertension.  However, across the population of people with chronic disease, smartphone adoption has lagged.  I felt like our strategy was vindicated when my friend Susannah Fox published research showing that folks with two or more chronic illnesses (independent of other variables such as age and socioeconomic status) use technology in the context of their health less than others.

The world of patient care appears to be catching up to the rest of mobile.  Not that I would ever endorse the irrational exuberance shown for mobile health apps in general, but some recent data points that changed my thinking are worth noting.

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A Second Look at the Link Between Obesity and Mortality

A controversial study published earlier this year in the Journal of the American Medical Association shows that overweight people have significantly lower mortality risk than normal weight individuals, and slightly obese people have the same mortality risk as normal weight individuals.


This meta-analysis, headed by statistician Katherine Flegal, Ph.D., at the National Center for Health Statistics, looked at almost 100 studies that included 3 million people and over 270,000 deaths. They concluded that while overweight and slightly obese appears protective against early mortality, those with a body mass index (BMI) over 35 have a clear increase in risk of early death. The conclusions of this meta-analysis are consistent with other observations of lower mortality among overweight and moderately obese patients.

Many public health practitioners are concerned with the ways these findings are being presented to the public. Virginia Hughes in Nature explains “some public-health experts fear…that people could take that message as a general endorsement of weight gain.” Health practitioners are understandably in disagreement how best to translate these findings into policy, bringing up the utility of BMI in assessing risk in the first place.

Walter Willett, chair of the nutrition department at the Harvard School of Public Health, told National Public Radio that “this study is really a pile of rubbish, and no one should waste their time reading it.” He argues that weight and BMI remain only one measure of health risk, and that practitioners need to look at the individual’s habits and lifestyle taken as a whole.

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The Strange Case of the C. Everett Koop National Health Award

The late Dr. C. Everett Koop was the most revered Surgeon General in history, perhaps even the most revered Cabinet member.  His calling card—indeed, his claim to fame – was his integrity.  A Reagan appointee, he acted as though he reported to no one other than the American people and his own conscience.  His penchant for candor and scientific independence fueled the federal government’s groundbreaking steps to raise public awareness about HIV/AIDS at a time when the tendency was to demonize and diminish.  He resisted incessant political pressure and refused to take positions or produce data that he knew to be false.

This drew strong support from both sides of the aisle, and even his detractors never questioned his honesty.  (Exhibit A:  The two authors of this posting, whose political views have little else in common other than respect for strong, independent-minded politicians.)

Dr. Koop’s legacy stands in sharp contrast to the eponymous award dispensed by The Health Project, whose committee members have turned their back on their founder. The last thing Dr. Koop would have expected is to see is *his* award bestowed upon  people who know that they don’t deserve it.  The 2012 award was given to three recipients for work done in Nebraska:  a vendor that claims wellness programs don’t even have to exist to save money, an outfit that can’t even spell the name of its own founder, and a state employee benefits plan that is under investigation for sky-high administrative costs.

Among the extravagant statements that formed the basis for the award (like claiming more than $20,000 in savings for every person who reduced their risk factors for a year, even though per-person spending is only $6,000), they claimed to have made 514 “life-saving catches” on employees with otherwise undetected cancer.  This data was obviously wrong to begin with — that cancer rate would have been at least 40 times greater than Love Canal’s.  Nonetheless, it sure sounded good, and the Governor of Nebraska himself was all-in too, so an award was issued.

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Getting Obamacare’s Messaging Right

Recently, there was a bit of a dust-up over whether it was appropriate for the Secretary of Health and Human Services (HHS) to engage the National Football League (NFL) to help HHS with the process of drumming-up enrollment for health insurance exchanges. In the end, the NFL and other sports leagues decided they were not going to be involved fearing the appearance of taking political sides.

In our view HHS is better off with this outcome. To our way of thinking the exercise would not have delivered the desired results and would have left individuals confused and created a political distraction. At the heart of most public health communication plans are three main functions: create a message, deliver the message and get people to act on the message (many variations: exampleexample, and example). The HHS/NFL combo would likely have failed the test:  What exactly does someone who catches a football for a living say that would make the uninsured purchase insurance on an exchange? While it’s easy to single out HHS and the administration, the opposition party also thinks messaging alone will solve all of its ills but that is far from correct assumption in our view. 

In terms of creating a message, our first instinct would be to recommend a governmental agency like the FCC but for healthcare. We would call it something like the clinical communications clarification committee (CCCC).  However, given recent concerns about “Orwellian” government information gathering, perhaps a more open-source, crowd-sourced approach to communicating may be more readily accepted. What we have in mind is a something like Pubmed meets Wikipedia where the information is readily available, credible, and based on updated facts. Inevitably something like this would need to be proctored to keep unreliable information out. Many crowd-sourced communities do a good job of self-policing but it couldn’t hurt to have an adult watching just in case.

Assuming we can create information (the message) in a way that is understandable and credible, how to transmit this information (the medium) becomes the next challenge. While we are pretty sure the “wired generation” who wear body monitoring devices are getting the “right” information via mobile devices, the web etc., we think that more important populations that are not technologically savvy may be missing out. Dual-eligibles for example, who are major drivers of cost and poor outcomes in the system, are not in our view, easily able to access useful information via high-tech gadgetry.

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Is Obesity a Disease? I Vote No

There is a certain irony in the nearly immediate juxtaposition of the rare introduction of a new FDA-approved drug for weight loss (Belviq) to the marketplace and the recognition of obesity as a “disease” by the AMA. A line from the movie Jerry Maguire comes to mind: “You complete me!” Drugs need diseases; diseases need drugs.

And that’s part of what has me completely worried. The notion that obesity is a disease will inevitably invite a reliance on pharmacotherapy and surgery to fix what is best addressed through improvements in the use of our feet and forks, and in our Farm Bill.

Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?

On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

If so, this, presumably, requires that everyone also have access to someone qualified to write a prescription or wield a scalpel in the first place, and insurance coverage to pay for it. We can’t expect people who can’t afford broccoli to buy their own Belviq, clearly.

There is, of course, some potential upside to the recognition of obesity as a disease. Diseases get respect in our society, unlike syndromes, which are all too readily blamed on the quirks of any given patient and other conditions attributed to aspects of character. Historically, obesity has been in that latter character, inviting castigation of willpower and personal responsibility and invocation of gluttony, sloth, or the combination. Respecting obesity as a disease is much better.

And, as a disease, obesity will warrant more consistent attention by health professionals, including doctors. This, in turn, may motivate more doctors to learn how to address this challenge constructively and compassionately.

But overall, I see more liabilities than benefits in designating obesity a disease. For starters, there is the simple fact that obesity, per se, isn’t a disease. Some people are healthy at almost any given BMI. BMI correlates with disease, certainly, but far from perfectly.

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Why Texting Public Health Messages Is a Brilliant Idea. Except When It’s Not…

A new service has partnered with a Los Angeles school district – the second largest in the country – to not only deliver STD results by text message, but also to promote the idea children share their “status” as easily as they share the highlight of their day on Facebook. But when it comes to children having sex, it’s never quite that simple now is it?

Qpid.me is the brainchild of Ramin Bastani and operates from the following premise: “We believe that sharing is a good thing and that it can lead to better sexual health decisions, more (safe) sex and fewer STDs.” Bastani went on to tell CNN in an interview: “If it’s cool for a beauty queen to share her STD status [Qpid.me’s celebrity sponsor is Tamie Farrell, Miss California 2009], then maybe kids will start to think it’s cool to share their own results. We want to normalize the idea of sharing your status.”

The process is fairly straightforward. Qpid.me requests patient test results from health clinics (with patient permission, of course) then transmits those results via text, email, and provides access to their online site. The concept of delivering STD results electronically is not necessarily new, or controversial. The danger lies in convincing children there are no concerns about sharing such private information among peers who may not respect their privacy, or, worse may shame them for contracting curable diseases.

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Guahao: VC Fantasy. Online Appointment Registration System for China’s 700 Million Internet Users


The promising platform is called Guahao (挂号网) and it claims to be China’s largest online appointment registration system.  With a national network of nearly 4,000 hospitals, 600 being Level-3 hospitals, and over 300,000 specialists, it is hard to dispute it’s size.*  Guahao began development in Shanghai 2010 in collaboration with the Chinese Health Education Network, Fudan Hospital and Healthcare Management Co., and the Chinese Hospital Association, and later expanded nationally.  Guahao attempts to alleviate the bitterness patients endure during a typical hospital visit.

*It should be known that there are actually several online appointment registration systems in China; However, most are small, regionally splintered and have questionable legitimacy.  Guahao is by far the largest and most well supported system in China.

China historically has not had a call-ahead appointment scheduling system.  Patients throughout China have long lamented the country’s hospital queuing system, or the lack thereof.  Patients arrive at the hospital, literally take a number, and wait for their turn – sometimes for over 24 hours.  It is not uncommon to see throngs of patients and their family members outside of the hospital, camping out in makeshift beds to see a physician.  A lack of appointment system puts pressure on the hospital’s health workers.  Patient scheduling provides predictability of patient flow and allows for more efficient allocation of healthcare resources.  Not to mention it makes for a much more patient-centered approach to healthcare delivery.

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Could Opening Up the Doors to the World’s Medical Research Save Healthcare?

What if you had access to all of the medical research in the world? Or better yet, what if the physician treating your particularly complex or rare condition had access to the latest research? Or what if a public health organization in your community could access that research to inform policymakers of measures to advance public health?

“Wait,” you may think, “can’t they already access that research? Doesn’t the Internet make that possible?” While unfortunately the answer to the first question is “No,” fortunately the Internet can make such access possible. As it is today, most physicians and public health professionals have very limited access to health research, almost all of which is published online. Only about a quarter of the research published today ends up being available to those working outside of universities, where libraries subscribe to a good proportion of the research journals.

So, what are these health professionals missing? What difference to their work would access to research make? Cheryl Holzmeyer, Lauren Maggio, Laura Moorhead and I seek to answer these questions with a new National Science Foundation study for which we are currently recruiting physicians and staff of public health NGOs.

We seek to demonstrate the difference it makes to the daily work of these health professionals to have easy electronic access to all the biomedical and public health research – or at least that large proportion held by Stanford University Library – for a period of eleven months (with one month of limited access as a control). To assess the impact of this access, we provide participants with a special portal to the research literature and track when and what research is viewed, while following up with interviews on the use and value of this access.

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Why You Probably Have a Lot Less to Fear From the Latest Superbug Than You Think

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such.

Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

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