Good Doctor, Bad Doctor- Call Someone that Cares

As much as most of us complain, it is truly a privilege to be a physician in the United States. There have been tons of articles and posts about “what it’s like to be a doctor”, but this submission focuses on what it takes to be a good (or a bad) one. The truth is that though we’re talking about physicians here, this can be applied to ANY type of worker, from doctors to cashiers, to accountants, to flight attendants, etc…

After a while, as much we’re taught not to judge, anyone in any medical community develops a sense of who’s “good” and who’s “bad” at their job. It’s very interesting to see how this happens as invariably, it is completely subjective. His good is her bad and vice versa. Increasingly people are reaching for more formal resources as guidance, however, the criteria that are being used to pass judgment are inconsistent at best. From hard facts like readmission rate, LOS, and hospital-acquired infections to a number of years in practice, the prestige of medical school/residency program, and social status to hours the office is open, reviews of office staff, and office address. I was even once told by a patient that he chose his doctor because of the electronic health record that was being used in their practice*!! None-the-less, I take issue with all of these quality “metrics”- I say that none of them are as important as would seem at face value…

In my primary role, I feel very fortunate to be looking at hard data all day long. Much of this data is about physician performance and it often takes an experienced eye to look past all the noise, deep into the data set to really uncover the sometimes hidden truth. It is very troubling for me to see someone that I KNOW is a great doctor be labeled as marginal by (complex) data. Our organization’s Physician Status Reports are carefully presented as “point-in-time” assessments of physician performance because they are! Anyone can get better (or worse) at any given metric tomorrow. It’s a continual process of growth and a part of every doctor’s commitment to lifelong learning. Do you think in 2018 doctors have a varying commitment to lifelong learning? But again, all of this is trivial…

So What’s the Answer?

Allow me to explain using a clinical vignette. A 32-year-old female with a fever, no chills, body aches, rhinorrhea (runny nose), anorexia (poor appetite).

What’s the diagnosis? Even my 9-year old would say, “Papa, this is a clear case of viral syndrome- antibiotics are not indicated here. Consider supportive therapy.” We should all be proud of his clinical acumen, for he is right! The point is that virtually anyone (or nowadays any connected device) can take a set of objective facts and perform a Bayesian analysis of the probability of any given diagnosis given signs and symptoms, but is that what a doctor really is? I think we would all overwhelmingly agree- No. A “good” doctor is much more than the guts of a good AI-engine. But let’s be more specific about what we mean and maybe even come up with a single, overarching metric for determining quality… read on!!

Some say that a good doctor is actually a healer- one that actually heals the patient, i.e. makes them feel better. A good doctor evaluates much more than just the symptoms of the disease but is deeply concerned about the patient overall well-being. Fever and productive cough of rusty-colored sputum is likely pneumonia, but what about the mass in the lower abdomen that eventually suppressed the immune system enough to succumb to the streptococcus pneumonia (that we all have in our normal respiratory flora)? What about the distant history of STDs that exposed the patient to the virus that triggered cancer that led to the mass? Who would think that a patients sexual history would have anything to do with rusty-colored sputum? The answer is: a doctor that CARES about her patient enough to spend more than the 30 seconds it would take to make the current diagnosis (and miss the real underlying root cause of the presenting illness). The rest of these findings would take even the most astute clinician a lot more time to elucidate from the average patient- time that they simply don’t have in today’s health care system (12 minutes on average).

Well, We’re All in the Business of Providing Care, Right?

Care is a word that is thrown around all the time both in healthcare speak and in real life. Care in health care can mean any of the following (according to Google):

  1. noun. The provision of what is necessary for the health, welfare, maintenance, and protection of someone or something.
  2. noun. Serious attention or consideration applied to do something correctly or to avoid damage or risk.
  3. verb. Feel concern or interest; attach importance to something.
  4. verb. Look after and provide for the needs of.

We most often use the word Care as defined in #1. Apprehensively, I think we often assume that #2–4 are inherent in conversations, but I wonder sometimes if it really is- EVERY TIME. I mean, the majority of healthcare workers care most of the time, but I think there are only a few that care every. single. time. On every interaction, they #2-#4- for these physicians, #1 happens automatically… My friends, allow me to propose that it is these workers that are our BEST doctors, cashiers, accountants, and flight attendants. It’s the ones that #2-#4, every time. Conversely, those that only #1 and don’t actively assume #2-#4, are just having a bad day.

But is it really anyone’s fault? Don’t we, as a nation, measure our desired outcomes? I have yet to come across the “CARE” measure in any of our most recent national policies or guidelines. Is Patient Satisfaction a surrogate of Care? Perhaps, but our current patient satisfaction metrics are only accurate for HOSPITALS, not individual doctors. Do we need evidence-based research to know that #2-#4 leads to better outcomes, less opioid-related death, increased patient satisfaction, better patient safety, and less physician suicide? Some would say we do. Do they really #2-#4? Wouldn’t it be great to measure how much they really care?

For most patients, modern medicine has made it easy to diagnose the medical condition, irrespective of the root cause. What modern medicine is increasingly failing to do is: heal the patient. It is my experience that irrespective of what type of #1 you provide, #2–#4 play a HUGE part in the healing process. By definition, Artificial Intelligence will NEVER be human and therefore incapable of providing #2-#4 for the masses, unless the masses change their definition of human first! This is more likely…

Let’s Ask the Right Questions

It turns out that we’re all just off on our frame of reference- it’s about every definition of the word care, #1-#4. The good news about what is being proposed here is that if you agree, you’ll realize that even the idea of “bad” doctors should be impossible… When ANY type of worker stops caring, isn’t that when they should seek something new? Sadly, no physician would disagree that the Care metric has been on a downward trend in the past decade. If it existed, the Care metric could help us all anticipate burnout and engagement waaayyyyy better, but what is really exciting is the potential effect it might have on our process improvement efforts!! How would our care environments look when every single worker #2-#4ed for every single task they performed?

If we all can agree on this proposal, the questions change for every one of our innumerable health care debates. The new question becomes: how can we enable doctors and health care workers to #1-#4 for their patients? Isn’t this what we all want from our health care system? I think we would all gladly pay for this type of care.

*Actually, the best determinant of health care quality is ACCESS to information, so this patient was actually smarter than the average bear.

Nutritional Inflation?!?! Who’d a Thunk it?

by
Rashida Ghauri, MD, ABIHM
Sarah Emslie
Baber Ghauri, MD, FHM, FACP, ABIHM

Introduction

We all understand that the value of the dollar is based on the relationship between the number of actual dollars in circulation and the number of precious resources we have in our federal reserves. When there are too many dollars floating around, economists call it inflation and suddenly your dollar is worth less today than yesterday. There is clear evidence that a similar thing is also happening with our FOOD supply!! Food today does not nearly have the same value as it did as early as twenty years ago!! We’re not talking about Twinkies here, we’re talking about apples, carrots, and other whole foods. As an example of this, most obese people are actually nutritionally deficient causing them to seek more nutritional value through more eating. Depending on the sugar/fat content of what they eat, they are usually entering the vicious cycle that leads to metabolic syndrome X, diabetes, and serious heart disease.
Nutritional inflation is something that most of us have never heard of and the purpose of this post is to help us understand the lethality of this phenomenon. There are a number of factors contributing to nutritional inflation:
  1. Selective breeding
  2. Crop management
  3. Modern farming methods
  4. Supply-chain management

Selective Breeding

One of the most important and furthest reaching factors in the loss of nutritional value of fruits and vegetables over the years is the selective breeding that humans have performed on plants. Tracing different crops back through history to their wild ancestors reveals that farmers always chose the sweetest and best tasting varieties to begin planting on farms, understandable when nutrition was not as understood as it is now. Studies of the nutritional content of plants now show that the most bitter and sour varieties actually have the greatest nutritional content in the form of compounds called phytonutrients. These compounds have been shown to fight cancer, cardiovascular diseases, and many other modern scourges. However, since our brains are wired to want sweeter, starchier food, we’ve often bred these compounds out of our crops. For example, Native Americans gathered wild dandelions in abundance in the springtime.  These plants have seven times more phytonutrients than our modern spinach. Their bitter taste made them not widely consumed and have never truly been domesticated in the way that other crops have because of it. Despite the low demand, it makes sense that they sell at premium cost at most grocery stores underlining the idea that the market cost of most food is directly proportional to its nutritional value.

Crop Management

A more recent culprit of nutrient loss can be found in the management and development of new crops. With the advent of refrigeration, crops could suddenly be transported across the country and still arrive fresh for consumption.  In addition, new farming equipment allowed for mega-farming producing never-before-seen yields. This change in the way that farming was done led to a push for higher yield crops, whether through selective breeding of the plants themselves, or the use of fertilizers and pesticides. These higher yielding crops have been consistently associated in studies with a downward trend in nutrient levels. In a study done in 1979 (Hughes et al.) raspberry plants were grown in soil that naturally contained phosphorus. One group was given no additional phosphorus-based fertilizer, and the other two groups were given increasing amounts of 22 ppm and 44 ppm. Although the additional fertilizer created large increases in the size of the plants themselves, it also caused a drop in almost every mineral that was measured in the plant, with the one exception of phosphorus. The fertilizer created more of the plant itself, but it was less
nutritious.
Figure 1. Dilution effects of phosphorus fertilization in red raspberry plants; 1, 22, and 44 ppm added to soil containing 12 ppm (Hughes et al., 1979; dry weight basis). The relative plant dry weight was respectively, 1:1.4:2.2.

Modern farming methods

It isn’t just what humans are putting into the soil that’s detrimental to the nutrition of our food, it’s also what’s being taken out. Modern farming methods are not kind to the soil, farmers often plant the same crop in the same field year after year, stripping the soil of its nutrients and forcing the addition of more chemical fertilizers in future years. Rotating different crops through different fields, or allowing fields to lay fallow for a year or two in between plantings gives the soil time to recuperate its lost nutrients. Restructuring the way that modern agriculture is practiced, and employing more organic growing methods may be one of the keys to recapturing some of the lost nutrients in plants.

Supply-chain management

What happens to crops after they’re harvested is also important. Before refrigeration was possible, crops were picked at the peak of ripeness and delivered straight to their destination, they would be on the tables of the people who purchased or picked them within a few days at the most. Sadly with the exception of our local farmer’s markets (and those who have their own personal gardens at home), this is not the case anymore. Food is picked weeks before it is ripe so that it will not spoil in transport, and is often left to languish in holding warehouses for yet more weeks where it is force ripened with ethylene gas before it ever sees the light of a grocery store display. So while the tomatoes you buy at the store may look perfect and red, being taken off of the vine and out of the sun while unripe, greatly reduces their nutritional value.

Solutions

So with all of these factors out of the general consumer’s control, this article may seem to paint a bleak picture of nutrition in modern times. However, it’s important to remember that there are things that we can do to ensure that we get the most nutrition possible out of our food.
  1. Cutting out as much processed food as possible from one’s diet is a great place to start.  Watch this How It’s Made classic on the 21+ steps it takes to produce household sugar: https://www.youtube.com/watch?v=cWl141Bu7fc
  2. Shopping organic or at farmer’s markets when possible is another quick way to get more nutrition in your food. Though obviously not possible for everyone, even the most antiquated grocers are understanding the value of selling organic and whole foods.
  3. Picking fruits and vegetables from the store with the darkest colors is a great way to ensure greater phytonutrient content even if they aren’t grown organically.
  4. For those who have the space, growing your own vegetables in the backyard or in pots is the best way to ensure the greatest nutritional content in your fruits and vegetables. You, the farmer, have complete control over the variety, harvest time, fertilizer, and pesticide use, all factors that have a huge influence on the nutritional content of your harvest!
  5. Ask your grocer!  Even if they don’t know the answer this time, chances are they will the next time.  The more we share this knowledge, the better we’ll eat!!

With the proper knowledge, you can make better choices about your food and help improve the long-term health and wellness of yourself and your loved ones.  The most important thing to remember from this post is that the COST of food is usually directly proportional to its nutritional value.

Want to learn more?  Here is a short video about the nutritional value of many commonly sold foods by the wonderful Dr. Michael Greger, MD, http://nutritionfacts.org.

References

  1. Davis, Donald R. “Declining Fruit and Vegetable Nutrient Composition: What Is the Evidence?” HortScience. American Society for Horticultural Science, Feb. 2009. Web. 2 Aug. 2016.
  2. Herro, Alana. “Crop Yields Expand But Nutrition Is Left Behind.” World Watch. Eye on Earth, n.d. Web. 2 Aug. 2016.
  3. “Leading Causes of Death.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 27 Apr. 2016. Web. 02 Aug. 2016.
  4. Ray, C. Claiborne. “A Decline in the Nutritional Value of Crops.” The New York Times. The New York Times, 14 Sept. 2015. Web. 02 Aug. 2016.
  5. Robinson, Jo. “Breeding the Nutrition Out of Our Food.” The New York Times. The New York Times, 25 May 2013. Web. 02 Aug. 2016.
  6. Scheer, Roddy, and Doug Moss. “Dirt Poor: Have Fruits and Vegetables Become Less Nutritious?” Scientific American. EarthTalk, 27 Apr. 2011. Web. 02 Aug. 2016.

The “Business Case” for Integrative Medicine

by:
Baber Ghauri, MD, MBA, FHM, FACP, ABIHM

Introduction

An undeniable fact of moving towards a standardized healthcare system is flattening of the distribution curve of physician performance.  The hope is that most of the flattening occurs through advances in efficiency through things like health information technology and training, but the fact is that those who underperform will be cut, and unfortunately for our society, those best performers that very often have other options will also drop out voluntarily.  With healthcare composing a large chunk of our gross national product, a career in healthcare is no longer synonymous with direct patient care and we are already seeing some of our communities best physicians reduce their clinical hours or even leave their beloved past-time altogether for other roles and opportunities.

As more and more of our best clinicians and diagnosticians transition their careers, those that remain will not be equipped to manage some of the more uncommon conditions, and Integrative Medicine may be the only answer for patients who are labeled for one reason or another as exigent.  Some such reasons include diagnostic complexity, social factors, and simply not enough time in the day among others.  Take for example the following case of diagnostic complexity:

The “Business Case”

Jane Pashond is a 45 year old caucasian female smoker that suffers from inflammatory bowel disease (IBD), eczema, depression, and obesity who presents with increasing fatigue, chronic pain, and digestive issues for many years.  She has seen many doctors and her exam is within normal limits as are her labs including her liver function tests.  Her typical office visits with her excellent care team which includes her primary care doctor and GI specialist are typically 12 minutes and 18 minutes respectively.  She is on multiple medications, some which require routine monitoring.  Her single visit copayment is $20 for her PMD and $35 for her GI specialist.   In one year, she is likely to spend almost $500 in copayments and over $1000 for medications, her total out-of-pocket cost of care is approximately $3500 which does not include her $3900 annual insurance premium.  Most importantly, this cost is considered the cost of maintenance care and does not account for exacerbations of any of her conditions which would easily double or triple her out-of-pocket costs for this care.

By now, Jane has spent over $7000 on her health care, all the while without any guarantee on her health forecast for tomorrow, living every day hoping that an exacerbation is not forthcoming.  Now that she has a high deductible insurance policy (she could not afford any other), which is almost $4000 more than her previous insurance plan.  An integrative approach to her care would uncover a number of root cause issues that are very uncommonly addressed by traditional allopathic care, the same type of care that earned me much acclaim for providing to my patients prior to my Integrative Medicine training, despite its often mediocre value.

Coupled with an Integrative approach, her depression, obesity, and eczema can be REVERSED and her IBD can be treated with simple diet and lifestyle changes that will also eliminate her fatigue, pain, and digestive issues.  Part of her dietary treatment will include a full nutritional assessment with a customized nutraceutical plan designed to be mimic or be subsidiary to traditional pharmaceuticals with almost none of the side effects.  The initial assessment will uncover heavy metal toxicity that is at the root cause of her eczema causing subclinical liver disease, not showing up on her liver function tests.  Through careful, time-intensive interviewing, her 20 year old water heater is found to have lead pipes which is eventually attributed to her recently worsening and progressive symptoms.  She will also learn about sleep hygiene and stress reduction.  This will significantly impact her IBD which,  by-the-way is actually IMPROVED by her cigarette use (this is evidence-based).  But since her IBD will be controlled better by a plant-based diet with low genetically modified organisms (GMO) and gluten, she will save an additional $2100 a year from smoking cessation.  If this sounds too good to be true, then you’ve been around the block enough to know that benefits from this philosophy of care have ENGAGEMENT by patients and providers as a prerequisite.  So why would Jane now, after all this time, all of a sudden be engaged?

“Patient Engagement, yeah whatever…”

Given the scenario it is very unlikely, but let’s just assume Jane is somewhat indifferent about her care.  In the past, there was little to no incentive for alignment of patients and providers because the out-of-pocket cost to patients was constant – essentially just an insurance premium along with a much lower, if any copayment for fee-for-service physician visits.  But in 2015, the potential $6100 savings is tremendous incentive for most patients to at least consider an Integrative approach (when offered), especially when their primary care doctor can share some of the savings with the patients’ payer.  With only minutes per visit, even the best trained primary care doctor or specialist can only meet this goal by engaging the Integrative specialist, who has at least 50 minutes per visit- more than enough time to have the conversations that are necessary to share the evidence and develop the trust for that all-important prerequisite, patient engagement.  More importantly, Jane can not even get an appointment with these high-demand providers in today’s increasingly competitive market for great care.

The problem is that Providers in the traditional payment system are not being given the time, training, or resources to offer patients low cost alternatives to traditional care.  These largely unknown interventions form the basis of the entire discipline of Integrative Medicine, which now requires fellowship training prior to eligibility for certification. With the rising cost of care delivery, this virtually guarantees that existing providers will not have the opportunity to pursue this training.  Serving as both a care delivery partner and an educational outlet, Integrative Medicine practices provide the time, training, and resources to our patients and providers alike to employ evidence-based integrative practice into their care management.

Conclusion

There are many Jane Pashond’s in our communities and the exciting part of our new healthcare marketplace is that our entire population of consumers are finally being incentivized to live healthier lifestyles.  Some would consider McDonald’s 30% drop in net income this year as partial evidence of this, the first time in their history.  Others might find the rising use of wearable health technology as proof.  Still others may just be trying to save the extra money by not getting sick in the first place and may enjoy the feeling of being stronger, faster, and having more energy and agility to play with their loved ones.  Whatever the reason, there’s no denying that Integrative Medicine has penetrated the healthcare marketplace.  The challenge lies in using evidence to educate our consumers into being able to make intelligent and informed healthcare purchase decisions.

Finally, I must say as a technologist that is usually looking for answers that are coming tomorrow, I am amazed at my increasing level of hope and belief on a set of 5000 year old disciplines as a major part of the solution to our healthcare delivery problems.  Considering Google defines Technology as “the application of scientific knowledge for practical purposes, especially in industry“, maybe I should be more inclusive of what I consider to be technology.