Hospitals and Health Systems in the Coronavirus Crisis

By JEFF GOLDSMITH (2)

Health systems all across the United States are reeling from a once-in-a-working-lifetime crisis brought about by the COVID-19 epidemic.  Hospitals, care systems and physician practices are hemorrhaging cash in the face of an expected oncoming flood of COVID patients.  Like the prelude to a tsunami, where the tide goes out a half mile, health system revenues have fallen 25-40% month over month, as normal patient care operations have receded. 

Patients have been reluctant to use hospitals over concern about their infection risk, and fresh worries about their ability to pay their share of the cost.   It is likely that the earnings impact will be much worse, since cases being cancelled are relatively high margin elective cases from patients with private insurance coverage that pays more than it costs to take care of them. 

Even with recent increases in Medicare payment rates for care for the COVID cohort, and an increase in federal Medicaid match to support state payments for the indigent and “differently abled”,  hospitals and the health systems will come tens of billions short.

Balancing hospitals’  safety net function of hospitals with their routine care mission is always tricky, particularly in communities with no public hospitals.   The United States commits less than 3% of total health spending on public health, and has chronically underinvested in mental health, infectious disease surveillance and disaster preparedness. 

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Coronavirus-like Symptoms

By ROB LAMBERTS, MD

My first possible COVID-19 case came nearly three weeks ago, before there were any cases in our city. He was a healthcare professional who presented with fever, sore throat, and cough. We did the usual strep and influenza testing, both negative, but I thought that he looked different. He had some diarrhea, stomach pain, and a different look to his face that I couldn’t place.

“You might have it,” I said. “You might have coronavirus.”

He looked at me nervously, obviously having thought the same thing. “Is there anything I can do about it? Can you test me?”

No, there were no tests anywhere at that point. Few states had access to any testing, so I knew all we could do was to wait. I sent him home and told him to go to the hospital if he developed shortness of breath, and that we’d get him tested as soon as possible. That seemed to be a short time, as my nurses contacted the national lab we work with and they told us that collection kits for COVID-19 were “on the way” and would get to us in 1-4 days. Perfect.

That was the start of a long odyssey of growing frustration, helplessness, and anger at the testing for this deadly disease. Those kits never showed up. By the time we had local access to testing, the patient had gotten completely better and was asking to go back to work. He works around very vulnerable patients and we told him to let his employer know about my suspicions and to get him tested. We never heard anything.

Of course, since then every cough has been a worry to my patients. Fevers are watched with dread. We have been directing people to contact our local academic hospital to be triaged for COVID-19 testing. A couple of them have been accepted, none has tested positive. Some of them have seemed suspicious to me, but the lack of adequate testing has the triage center restricting tests to the very vulnerable or the obviously sick.

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Time to Have an Idea

By CHRIS DWAN

What are the most important pieces of professional advice you’ve ever received?

I remember one of mine clearly: It was in late 2004, and my colleague Bill told me that it was “time to have an idea.”

I had hired in as the first employee at a small consulting company in early summer. The founders had been handing me pre-specified projects for a few months. These early projects appeared on my desk ready-made, with the Statement Of Work (SOW) already written, the scope negotiated, and the customer interested mostly in when the resource (me) could be scheduled.

Now it was fall, and it was time for me step up my game and spec my own work. I realize now that they were tired of carrying me.

In the spirit of “learn by doing,” they dumped me on the phone with a prospective customer, the IT department for Stanford.

That, in itself, was an incredible opportunity.

Rookies look down on “sales.” I know now about the grinding work that leads to calls like that. The series of interactions with gatekeepers whose only options are to say “no” or else to continue the conversation. The people on the other end of this call could say “yes.”

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Networks and Risk in the Age of Coronavirus

By DAVID SHAYWITZ, MD (1)

Technology has been hailed for its ability to connect us; we’ve tended to view this is a positive development, but as rare, high-impact events like the coronavirus epidemic reminds us, a densely-networked world may also be more fragile.

The mixed blessing of interconnectivity was acknowledged back in 2005 by New York Times columnist Thomas Friedman, who observed:

“…we are now in the process of connecting all the knowledge pools in the world together. We’ve tasted some of the downsides of that in the way that Osama bin Laden has connected terrorist knowledge pools together through his Qaeda network, not to mention the work of teenage hackers spinning off more and more lethal computer viruses that affect us all. But the upside is that by connecting all these knowledge pools we are on the cusp of an incredible new era of innovation, an era that will be driven from left field and right field, from West and East and from North and South.”

For techno-optimists like Erik Brynjolfsson and Andrew McAfee, authors of The Second Machine Age, improved interconnectivity catalyzes what they call “recombinant innovation.” This is the idea that “the global digital network” enables us to “mix and remix ideas, both old and recent, in ways we never could before.”

They continue: “Digitization makes available massive bodies of data relevant to almost any situation, and this information can be infinitely reproduced and reused because it is non-rival. As a result of these two forces, the number of potentially valuable building blocks is exploding around the world, and the possibilities are multiplying as never before.”

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A Little Context on Coronavirus For At-Risk Patients

By DAN STONE, MD

Joe, a semi-retired 81-year-old, never expected his Italy guys’ trip to thrust him into the front ranks of COVID-19 patients. Joe’s story goes against the grain of news about the coronavirus now gripping the world and providing epidemiologists and public health experts with the challenge of their professional lives.

Joe is a patient of a medical colleague, and he and his wife gave me permission to tell their story. It started with a ski vacation for 14 friends, united by their connections to the real estate industry, who flew from Sweden, San Francisco and Los Angeles to a rendezvous in Munich. From Germany they traveled to Selva di Val Gardena, a ski resort in the Dolomite mountains of northern Italy. Arriving on Feb. 21, they began their usual regimen of morning ski runs and afternoon lounging.

Before long, they could tell something was off. Joe’s friend Peter was the first to develop a cough and general malaise. Some of the others soon noted more shortness of breath than usual on the slopes. In the evening, normally robust appetites faded. By the time the trip ended, Peter was seriously ill with a cough and fever. He was hospitalized in Munich with pneumonia. Although Joe felt unwell, he was able to continue to Los Angeles.

By the time Joe arrived at LAX on March 1, he realized that he might have been exposed to COVID-19. He called Dr. Jonathan Weiner, his primary care doctor, from the airport. Weiner, aware of the public health implications of a potentially infectious patient in a public setting, directed Joe to head home and arranged follow-up care there with the Los Angeles County Department of Public Health.

Joe tested positive for COVID-19 as have all the other trip participants. He has no idea how they could have been exposed, although he thinks back to a crowded tram ride. Since testing positive, Joe has been isolated from all direct interpersonal contact. Confined to a bedroom at home, he communicates with his wife, Barbara, by cellphone, text and Facetime. Barbara is quarantined too. Because test kits and lab time remain limited, and because she exhibits no symptoms, she hasn’t been tested and she won’t be unless she develops a fever or cough.

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It’s Always Darkest Before the Dawn: What the War on AIDS Can Teach Us About COVID-19

By ANISH KOKA, MD (5)

As the globe faces a novel, highly transmissible, lethal virus, I am most struck by a medicine cabinet that is embarrassingly empty for doctors in this battle.  This means much of the debate centers on mitigation of spread of the virus.  Tempers flare over discussions on travel bans, social distancing, and self quarantines, yet the inescapable fact remains that the medical community can do little more than support the varying fractions of patients who progress from mild to severe and life threatening disease.  This isn’t meant to minimize the massive efforts brought to bear to keep patients alive by health care workers but those massive efforts to support failing organs in the severely ill are in large part because we lack any effective therapy to combat the virus.  It is akin to taking care of patients with bacterial infections in an era before antibiotics, or HIV/AIDS in an era before anti-retroviral therapy.  

It should be a familiar feeling for at least one of the leading physicians charged with managing the current crisis – Dr. Anthony Fauci.  Dr. Fauci started as an immunologist at the NIH in the 1960s and quickly made breakthroughs in previously fatal diseases marked by an overactive immune response.  Strange reports of a new disease that was sweeping through the gay community in the early 1980’s caused him to shift focus to join the great battle against the AIDS epidemic. 

The first reported cases of AIDS were reported in the United States in the 1981 Morbidity and Mortality Weekly Report.  5 young men, all previously healthy and all active homosexuals were found to have Pneumocystis carinii pneumonia, a disease that prior had been restricted to the severely immunocompromised.  An avalanche of clinical reports subsequently woke the nation to a disease that appeared to have a predilection for the gay community.  The remarkable subsequent successes of medical therapies that followed to make AIDS a manageable disease to grow old with are now a matter of history, but in the early years this success seemed anything but inevitable.

The charge leveled against the establishment of the day by a public becoming aware of the tragedy of young, previously healthy individuals dying by the thousands was that there was an attempted cover up of a ‘dirty’ disease in a community America would rather not talk about.  But from the first description of the disease by the medical community, the activity in the research industry (both public and private) was intense.  It took 2 years for two labs to simultaneously identify the HIV virus that appeared responsible for the development of AIDS.  Elaborating the mechanism by which the virus destroyed the body’s immune system lead to the discovery of potential therapies. 

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The Trojan Virus – COVID19

By NIRAN AL-AGBA, MD

The Trojan Horse is a tale about subterfuge.  After a decade of war, the Greeks had made little progress against the Trojans so they constructed a huge wooden horse and hid a select force of men inside.  Believing the Greeks sailed away, the Trojans pulled the horse into their city as a victory trophy. That night the Greeks crept out of the horse and unlocked the gates for their fellow soldiers, who had sailed back secretly.  The Greeks ended the war by destroying the City of Troy.

COVID-19 is our Trojan Horse.  It has snuck inside the gates and attacked.  How do we fight against an enemy we don’t entirely understand?

When the first presumptive positive case was reported in Kitsap County this week, my clinic began screening patients and their parents for fevers.  As a result, not a single febrile person has stepped through my front door since last Monday, March 9.  There is a temperature triage station set up under a Seattle Seahawks tent in front of my clinic.  For the record, I am no fan of professional football, and I never imagined it would serve as a triage station.

If a patient has a fever, they are asked to return to their car for what is now called a “car visit.” During the measles outbreak, I did “car screenings” to make clear patients to come in to the clinic if they had a rash.  Examining young children out in freezing temperatures while standing outside a car is a whole different thing entirely.

There is no precedent here.   

For a “car visit,” I leave my office and walk into an empty building next door.  In there, I  put on a different jacket (in lieu of a gown, which I don’t have), safety glasses and an N-95 mask, pick up my leather doctor bag—which contains its own set of medical equipment, pen, prescription pad, and other essentials—and walk to the patient’s car, which is waiting in a makeshift “drive through” spot next to my clinic.  

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COVID-19 Update: Friday the 13th Edition

By ROB LAMBERTS, MD

Hello, and welcome to our new world! Sports has been cancelled, concerts have been cancelled, toilet paper is scarce, and don’t you dare cough in public! The new catch phrase is “social isolation,” which is difficult for many, but easy for some. At last, a crisis that favors the introvert!

Update on Current Situation

To date, there have been over 140,000 documented cases of the virus worldwide, and more than 1800 in the US. More than 5800 people have died, 41 of whom were in the US. Countries have shut down social gatherings, have limited travel, and the president has declared a state of emergency.

To date, there have been no cases in our local area, but I’m fairly certain the infection is everywhere, as it spreads easily from person-to-person and so containment is difficult. We have had suspicion of infection in our patient population, and are moving to get testing supplies so we can confirm or disprove the diagnosis.

The current public health goal is to decrease social contact to slow the spread of the virus. This is why the enormous sports industry has shut down, despite huge financial losses incurred by doing so. This is why conferences, concerts, and even family gatherings are being cancelled. This is why everyone is washing their hands frequently (and hoarding hand sanitizer).

I have no idea why people are hoarding toilet paper.

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A Brief Fact-Based Message From Your Doctor on Coronavirus (COVID-19)

By ROB LAMBERTS, MD

Updated – 3/11/2020

Things are developing regarding the spreading epidemic/pandemic and so here is an update to let you know the state of things, what we are doing, and what you should do.

There have now been more than 120,000 cases worldwide, with over 1000 in the US. Italy (as an example of what could happen here) is in crisis, with more than 10,000 documented cases and ER’s and hospitals flooded with very sick patients. Schools across the US (including Atlanta) have closed to decrease the spread of the virus. The pattern of illness remains the same:

  • People present with a flu-like illness (fever, body aches, cough) with focus of infection more on the lungs.
  • Children are largely spared from the severe disease, with the majority of deaths being in the elderly or otherwise high-risk individuals.

The problem we face here is twofold:

  1. We don’t have a good test available to diagnose COVID-19 in a clinically useful way (rapid and simple)
  2. Even if we did, there is no clear treatment for COVID-19, other than supportive care.

How We Are handling patients with Flu-like Symptoms

  • We are trying to identify patients who may have coronavirus and treat them outside of our clinic. While we want to help people who are sick, we don’t want to expose high-risk people to the virus. So…
  • We ask that if you have a fever or flu-like symptoms, that you do not come into the office. Instead we ask you to contact us via phone, email, or via Spruce. Be patient, as we are likely very busy with other sick people!
  • Please tell us about your symptoms and we’ll guide you in what to do next.  This may include triage and evaluation in our parking lot.  Remember that we cannot diagnose you, and we cannot give you any treatment if you do have the virus. Yes, that makes things very difficult for all of us, but it is the situation we face.
  • Also understand that we may have high-risk people at the office with other problems. Infected individuals in our office may spread the infection to others, so please understand, and don’t demand special treatment.
  • If possible, do not come to the office if you are a high-risk person:
  • – Over age 70
  • – Diabetic (poorly controlled)
  • – Significant lung problems (COPD, moderate/severe asthma)
  • – Other immune-compromising problems or medications.

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Please Don’t Triage Me

By FRANCINE HARDAWAY

I’m writing this for the ER doc who I have a feeling I’m going to be meeting one day soon.

I thought I’d introduce myself.

I’m the one who is going to be triaged: 78 years old, comorbidity of hypertension, not enough useful life left to bother with.

How do I feel as one of the people in the at-risk category? Awful. Mentally awful. There’s no way to escape this virus. Not the virus, but the knowledge that the country is in a state of chaos, doesn’t have enough hospital beds or ventilators, and will be resorting to triage, even though nobody is admitting it yet. I hear the dire predictions about people dying in hallways in my sleep.

Which is not, of course, how I viewed my life two weeks ago. 

That person I saw in the mirror? Still self-supporting, a yogi and a denizen of the gym.  Flexible and fit. Walking 4 miles a day. Still pretty mentally sharp. 3 dogs and a huge network of social connections. Three or four invitations to lunch and dinner every week.

But now my life has been turned upside down. Outside of walking the dogs, I’m a shut-in. If I have to go to the grocery store, I go just as it opens, and I wipe my cart down carefully. I run into the house, put the bags down on the table, and wash my hands. I feel like I have taken an unnecessary risk for navel oranges, vegan cheese and salt free snacks.

I’ve done all the reading. Virologists are the worst for making people fearful. They deal in worst case scenarios. Then come the engineers, who are good at predictive analytics. Many of my younger friends are in Silicon Valley, and they’re hunkering down. They took their kids out of school weeks ago.

In sunny Arizona, day after day they tell us we have nine cases. They’ve canceled all our tourist season, so other than community spread, we won’t have outside infection. Or will we? Or do we already?

I know too much.  I’ve been in health care one way or another for most of my working life, either married to a physician or helping health-related companies get started, or marketing them. So I know that although I’m taking all the precautions I can, I’m never totally sanitized. I feel like climbing into the shower and staying there. I put vaseline at the end of my nose every morning.  I pray to my nasal passages: cilia, keep me free. I order immune-boosting herbs.

 I’d like to call a local emergency room and find out if they are overrun. I’m starting to look for ER docs in my network, just to see what’s really happening, because they have the best chance of knowing.

The women I walk dogs with in the morning have differing political beliefs. We argue a lot, partly because we disagree, and partly because it’s the only fun we have. I’m the yogi, the one who keeps pointing out that we’re stuck with each other for the next six months at least, and we have to get along.

You can imagine what my political beliefs are. I have become some sort of fanatical conspiracy theorist. But this is wrong. Why should it be President Trump’s responsibility to come up with a plan?  Where is the healthcare industry? They’re the ones who decide the number of beds we will have, and how to spend money they could have spent on ventilators and respirators. If they’ve spent it on their own salaries and profits, that’s not his fault. I’ve fallen down a rabbit hole trying to get back to first causes. If we had universal coverage, if we had pandemic planning, if we had more money given to health and less to the military, if,if,if…

But we are where we are. I’m going to put on some disco music and do some floor exercises at home, all while wondering how clean my floor actually is.

Diagnosing the Strange Malady and Perplexing Symptoms That Afflict Your EHR

By RICHARD GUNDERMAN, MD and MOHSIN MUKTAR (3)

Ironically, the same electronic health records (EHRs) initially designed as a tool to help physicians diagnose diseases have largely evaded diagnostic scrutiny. Talk to physicians who utilize them on a daily basis, however, and it becomes abundantly clear that today’s EHRs are ailing. They are adding hours to the physicians’ workday, siphoning attention from patient care, and sowing the seeds of demoralization across the profession of medicine. To address this problem effectively, physicians need to shift their focus from the symptoms associated with EHRs to the underlying diagnosis.

A key to arriving at the most accurate diagnosis is to cease treating EHRs as information technology problems and instead regard them as organic problems, not so different from the categories we would use in diagnosing a patient. Specifically, we need to seek out a known disease or diseases onto which many of the problems with EHRs can be mapped. In so doing, it is not our intention to stigmatize any disease or the patients who suffer from it, but instead to help physicians peer more deeply into the nature of the electronic malady with which they are wrestling.

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Seven for the Twenties: A Futurist Looks at the Next Decade

By JEFF GOLDSMITH (13)

After a decade dominated by ObamaCare- its enactment in 2010, the fraught implementation, its near repeal in 2017, and the welter of inconclusive experiments with Medicare payment reform – healthcare in the 2020s is likely to be reshaped by technological and scientific advances, as well as continued political struggles over societal and family cost.  We can expect major change in seven areas:

1. Rising Patient Safety Risks. 

Two emerging patient safety risks will spike in seriousness during the 20s.  One risk, that of drug resistant bacterial infections, boiled under the surface for more than two decades, with the rise of MRSACandida aureas, Clostridiodes difficele and more than a dozen other agents.  

Nearly three million people were infected with these agents in 2017, and more than 48 thousand died.  While hospital infection control has improved, and deaths from hospital infections fell during the 2010’s, antibiotic drug development has lagged, and the potential for one or more breakout infection risks is highly likely in the 2020s.   The Economist published a chilling and entirely possible scenario in July, 2019.

The second major risk has resulted from the confluence of two information technology (IT) trends-  the migration of health system clinical and financial operations to the Cloud and the 5G-enabled connectedness of medical devices and hospital infrastructure to the Internet, the so-called Internet of Things (IOT).  These two linked migrations opened a gaping digital “back door” in hospitals and systems to “black hat” hackers.

The fall of  2019 saw two major health systems-Tuscaloosa-based DCH Health System (AL) and Hackensack Meridian (NJ) – succumb to ransomware attacks that paralyzed clinical operations for days before the system paid cyber-extortionists to stand down.  However, there is a more threatening risk of mass patient casualty episodes in hospitals if hackers gain control over critical life support functions like respirators, infusion pumps, oxygen systems, HVAC and electrical systems.

The virtually unmanaged spread of connected devices and systems in hospitals is a significant threat to patient safety.  Health systems and regulators will be playing catch up in both these patient safety domains during the 20s as the degree of patient risk becomes more clearly understood.  

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My Life In Hell

By ROB LAMBERTS, MD (2)

“What diagnosis do you want to use for those ear drops you sent on Mr. Johnson,” Jenn texted me. “ICD-L21.8 for seborrheic dermatitis?”

Sigh. Welcome to prior-auth hell.

These are generic ear drops I ordered for presumed fungal infection of the external ear. The cash price for the drops is $15 for a 10 milliliter bottle (I checked before prescribing them). “No,” I responded, “it would be ICD-B36.9 for otomycosis.” (translation: ear fungus)

Jenn tried submitting this new diagnosis without success. She then noted that this medication was supposed to be authorized without need for authorization, so she called the pharmacist, who ran the 30 milliliter bottle through the computer system and the medication was authorized. That size bottle goes for $27 cash.

Rob bangs head on wall.

But Jenn didn’t yell. She didn’t say any profanity (that I could hear). Jenn’s a saint. She lost 30 minutes of her life to this nonsense, as did the pharmacist. As for me, I just got a little extra blood pressure points, a little acid corrosion of my stomach, and a stronger desire for beer when I get home this evening.

While my practice doesn’t accept money from insurance companies, we do serve our patients for the sake of their health. This means that we advocate on their behalf in a system that seems hell-bent on making care less accessible. Prior-auth hell is one example of this wall that has been built up between people and reasonable care. Electronic medical record hell, pharmacy trickery hell, specialist non-communication hell, bloated hospital gouging hell, media non-story hype hell, and opportunist alternative medicine hell are all contributors to the hell-fire heat we are all feeling.

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An Unfortunate System of Reimbursable Events

By JOE FLOWER

Leading lights of the health insurance industry are crying that Medicare For All or any kind of universal health reform would “crash the system” and “destroy healthcare as we know it.”

They say that like it’s a bad thing.

They say we should trust them and their cost-cutting efforts to bring all Americans more affordable health care.

We should not trust them, because the system as it is currently structured economically is incapable of reducing costs.

Why? Let’s do a quick structural analysis. This is how health care actually works.

Health care, in the neatly packaged phrase of Nick Soman, CEO of Decent.com, is a “system designed to create reimbursable events.” For all that we talk of being “patient-centered” and “accountable,” the fee-for-service, incident-oriented system is simply not designed to march toward those lofty goals.

A machine for creating reimbursable events

The health care system is a machine for creating reimbursable events. This means that its systemic business aim is to maximize reimbursable events and to increase their price, that is, to maximize the energy the system can draw in from its customers.

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Can a Dying Patient Be a Healthy Person?

By RICHARD GUNDERMAN, MD (9)

The news was bad. Mimi, a woman in her early 80s, had been undergoing treatment for lymphoma. Her husband was being treated for bladder cancer. Recently, she developed chest pain, and a biopsy showed that she had developed a secondary tumor of the pleura, the space around one of her lungs. Her oncology team’s mission was to share this bad news.

Mimi’s case was far from unique. Each year in the U.S., over 1.6 million patients receive hospice care, a number that has been increasing rapidly over the past few years. What made Mimi’s case remarkable was not the grimness of her prognosis but her reaction to it.

When the members of the team walked into Mimi’s hospital room, she was lying in bed holding hands with her husband, who was perched beside her on his motorized wheelchair. The attending oncologist gulped, took a deep breath, and began to break the news as gently as he could. Expecting to meet a flood of tears, he finished by expressing how sorry he was.

To the team’s surprise, however, no tears flowed. Instead Mimi looked over at her husband with a broad smile and said, “Do you know what day this is?” Somewhat perplexed, the oncologist had to admit that he did not. “Today is very is special,” said Mimi, “because it was 60 years ago this very day that my Jim and I were married.”

The team members reacted to Mimi with astonishment. How could an elderly woman with an ailing husband who had just been told that she had a second, lethal cancer respond with a smile? Compounding the team’s amazement, she then went on to share how grateful she felt for the life she and her husband had shared.

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How to Make Friends 2.0

By NIKHIL KRISHNAN

We have a loneliness problem as a society.

Cigna conducted a survey on 20,000 of their members.

  • 54% said they always or sometimes feel that no one knows them well.
  • 56% reported they sometimes or always felt like the people around them “are not necessarily with them.”
  • 40% felt like “they lack companionship,” that their “relationships aren’t meaningful” and that they “are isolated from others.”

It’s probably no surprise to most people that it’s actually pretty hard to make friends, especially after college. It’s felt so universally that it’s become an extremely popular genre of meme.

As a thought experiment, what would you do if you moved to another city where you didn’t have an existing network? It’s a pretty daunting proposition without a ton of options (Work friends? Sports league? Meetups?).

We have online tools to connect and organize better, but it feels like they’re creating relationships that are more hollow and circles that are more insular.

Can we use them to make it easier to make friends?

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Remember When Doctors Were Heroes?

By KAREN SIBERT, MD (3)

For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, nine years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.

Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.

Remember when physicians were heroes?

For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.

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Healthcare and Evangelism
(Silicon Valley Edition)

By DAVID SHAYWITZ, MD (7)

The unofficial mantra of silicon valley entrepreneurs may well be fake it ‘til you make it, an approach of resilient bravado that’s led to a slew of ultimately successful tech giants – and also to frank deceptions like Theranos.

Recently, I heard from VC Marc Andreessen (on the a16z podcast, here) what must be the most forthright explanation of this approach, a sales technique Andreessen calls “evangelistic selling.”

Andreessen was responding to a question about how do you sell into businesses that aren’t intrinsically receptive to change (i.e. essentially every large established business, including those dominating healthcare).

The Evangelistic Sale

First, you can see why some view Silicon Valley denizens as merchants of hype – this is, if not explicitly what Andreessen is championing, perhaps an inevitable outcome of his approach: entrepreneurs and (other) salespeople talking up an often-fantastic vision of a yet-to-be realized future.

Andreessen also points to the example of Elon Musk and Tesla; Musk is often criticized for overselling, says Andreessen, but argues Musk had to paint a vision not only of a car you could plug in, but also a whole system of superchargers along freeways, and his vision had to be compelling enough so he could actually sell enough cars “into that vision” to afford to start installing the chargers he described, and enable the vision to become a reality (which, initially, it wasn’t). Andreessen likens it to selling the first fax, which obviously wasn’t especially useful until and unless it was adopted by others.

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Are Hallucinogens the New Miracle Drug?

By GEORGE DAWSON, MD (6)

Steve Jobs:  “Taking LSD was a profound experience, one of the most important things in my life.  LSD shows you that there’s another side to the coin, and you can’t remember it when it wears off, but you know it.  It reinforced my sense of what was important – creating things instead of making money, putting things back into the stream of history and of human consciousness as much as I could.”  (ref 1)

Woodstock (Chip Monck):  “To get back to the warning that I received. You may take it with however many grains of salt that you wish. That the brown acid that is circulating around us isn’t too good. It is suggested that you stay away from that. Of course it’s your own trip. So be my guest, but please be advised that there is a warning on that one, OK?” (ref 2)

Warning: The final few paragraphs of this post contain language that some may find offensive.  I included it for a reason.   In 30 years of practice and in my real life – I have found that many people talk this way.  If profanity offends you don’t read the end of this post.

Everywhere I turn these days – whether it is a blog or more traditional media I am struck by the same stories on hallucinogens.  If you believe what you read out there, hallucinogens are magical drugs in that they are almost totally benign, consciousness expanding, and they can treat your anxiety or or depression.  They have been actively discriminated against like other illegal drugs and that is the only reason we have not done the research to prove that they can treat many problems.  Back in the 1970’s we would have said that “The Man” is restricting access to valuable consciousness expanding drugs and if “The Man” was overthrown – the world would be a much better place.  I have briefly reviewed the same lines of rhetoric that occur with cannabis.  I have not heard similar arguments with ketamine, probably because fewer people have experience with it and it is a more difficult drug to use, even in a medical setting where the drug has a known concentration and purity. 

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Stabbed in the Back: Confronting Back Pain in an Overtreated Society

By NORTIN HADLER, MD

To live a year without a backache is abnormal.

Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly. 

Almost all of the people we will be talking about in this book were afflicted with regional backache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.1 Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.

While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price. 

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Enriching Data Can Impoverish Reality

By RICHARD GUNDERMAN, MD

Medical historian Stanley Reiser wasn’t kidding when he entitled his best-known book, “Medicine and the Reign of Technology.”  To a large degree, technology has taken over medicine.  I am not talking primarily about our increased reliance on such technologies as advanced imaging equipment or assistive procedural devices.  In such cases, the technology remains largely a tool, and the wielder remains basically in charge.  I am talking about a far more pervasive and insidious form of technology whose very name tells a good part of the tale – health information technology.

Many physicians and other health professionals find health information systems clunky, perverse, and intrusive, but their problems go far deeper.  Underneath unwieldiness lies the temptation that we begin relying on such indicators to such an extent that we stop attending to our internal resources.  Consider the case of the patient said in his admission note to be “status post BKA” – below the knee amputation – but who turns out on rounds to have ten toes.  What happened?  DKA – diabetic ketoacidosis was mis-transcribed into the medical record as BKA, and the error simply propagated like a virus.

At stake is what we mean by knowledge.  Is what we know defined by our own experience – what we have seen, heard, felt, and perhaps even intuited in the presence of the patient?  Or do we instead rely on what is represented on a computer screen?  Which is a more likely occasion for us to exclaim, “That can’t be right!” – when what the computer screen indicates does not comport with what we have observed of the patient, or when what we have observed in the presence of the patient does not jibe with what the computer is telling us? 

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The Health Care Reform Expert-Industrial Complex

By MARGALIT GUR-ARIE ( 4 )

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

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Warren v. Dinter: Should HMOs and ACOs be Accountable for Malpractice?

By KIP SULLIVAN, JD (10)

Three weeks ago I posted a comment here about a decision by the Minnesota Supreme Court in the case of Warren v. Dinter. In that case, the court held, by a 5-2 margin, that hospitalists (and, therefore, the hospitals they work for) can be sued for malpractice even if they were not in a treatment relationship with the patient. I took the position that that decision was the right one. (If you haven’t read my first article, I urge you to do so to understand the facts of the case.)

The ensuing discussion about my article focused primarily on which, if any, of the three health care professionals involved in the decision not to hospitalize Susan Warren were culpable. The question of whether other parties – the hospital, the chain that owned the hospital, Accountable Care Organizations (ACOs) established by the chain, and insurance companies – should be subject to liability received relatively little attention. Two who did comment explicitly on that issue made it clear they thought even asking about third-party culpability was verboten.

In this sequel to “Why did Susan Warren die?” I want to focus on the question, Shouldn’t third parties who make, veto or influence medical decisions be exposed to malpractice lawsuits? My answer is yes. If the answer is yes, then we must support the Warren v. Dinter decision. Imagine if the Minnesota Supreme Court had taken the opposite position. Imagine that the court decided that injured patients cannot sue third parties unless the employee of the third party (the doctor or nurse) who made the decision in question was in a treatment relationship with the patient. Is it not obvious that such a decision would slam the courthouse doors on all patients injured by employees working for insurance companies, hospitals, hospital-clinic chains, and ACOs who were not treating the patients? 

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Health Apps, Data Sharing and the Trust Deficit

By SUSANNAH FOX (17)

There has been a steady drip-drip-drip of articles documenting how health apps are sharing data with third parties:

Data sharing practices of medicines related apps and the mobile ecosystem: traffic, content, and network analysis, by Grundy et al. (British Medical Journal, Feb. 25, 2019)

Is your pregnancy app sharing your intimate data with your boss?As apps to help moms monitor their health proliferate, employers and insurers pay to keep tabs on the vast and valuable data, by Drew Harwell (Washington Post, April 10, 2019)

You Give Apps Sensitive Personal Information. Then They Tell Facebook. Wall Street Journal testing reveals how the social-media giant collects a wide range of private data from developers; ‘This is a big mess’, by Sam Schechner and Mark Secada (Wall Street Journal, Feb. 22, 2019)

Assessment of the Data Sharing and Privacy Practices of Smartphone Apps for Depression and Smoking Cessation, by Huckvale, Torous, and Larsen (JAMA Network Open, 2019)

This post is my chance to share some relevant data, add my perspective, and ask for your input.

First, the data from a 2018 Hopelab/Well Being Trust study I helped write:

  • 71% of female teens and young adults say they have tried mobile apps related to health, compared to 57% of males. Three in ten (30%) females say they currently use a health app, compared to two in ten (20%) males.
  • Fully 48% of females ages 18- to 22-years-old and 25% of teen girls say they have used a period tracking app, compared with 2% of males.
  • Sixteen percent of females use a meditation app, compared with 5% of males.

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Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other

By KIP SULLIVAN (25)

Two bills that are called “Medicare for all” bills by their supporters have just been introduced in Congress. On February 27, Representative Pramila Jayapal introduced the Medicare For All Act of 2019, HR 1384 , in the House of Representatives. On April 10, Senator Bernie Sanders introduced a bill bearing the same name in the Senate, S 1129. The cost-containment section in Representative Jayapal’s bill will cut health care costs substantially without slashing the incomes of doctors and hospitals. Senator Sanders’ bill cannot do that. 

In this article, I explain the differences in the cost containment sections of the two bills and call upon Senator Sanders to correct two defects in his bill that minimize its ability to reduce costs. Defect number one: S 1129 authorizes a new form of insurance company called the “accountable care organization” (ACO). Defect number two: S 1129 fails to authorize budgets for hospitals. Representative Jayapal’s bill, on the other hand, explicitly repeals the federal law authorizing ACOs, and it authorizes budgets for individual hospitals. 

I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders. Bernie’s enthusiastic support for a “single payer” solution to the American health care crisis has added millions of new supporters to the single-payer movement. But precisely because he is now the most recognizable face of the single-payer movement, it is extremely important that all of us, whether we’re already in the single-payer movement or we just long for a sane and humane health care system, encourage Bernie to fix the defects in his bill. 

To explain the two defects in S 1129, I must first explain why a single-payer bill like Representative Jayapal’s will be effective at cutting the high cost of American health care. I begin by explaining the origin and meaning of the “single payer” label. I will then describe the two defects in S 1129 in more detail.

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