Monday, July 30, 2012

The Secret to Losing Weight

 I know the secrets of medicine.  Back in medical school, during an initiation ritual, in the darkness in a room lit only by candles, those secrets were shared with me.  I have been sharing them with selected others for many years, after receiving their solemn oath to use such powerful information with only seriousness of purpose and gratitude towards those who first were given this knowledge by the elders of medicine (no I am not talking about the editors of the New England Journal of Medicine.  They are among those who try to keep it secret which, if you read it regularly you understand.)  My only goal is to clear the mist and shine a light on these secrets.  My ultimate goal is to open medicine to the public as it is too important to be left only to doctors.  Rob Spiro’s (for total clarity I admit he is my son) article in the Huffington Post and the recent pilot launch of his company Good Eggs, has inspired me to start revealing these secrets to a wider audience through my blog (so that both of you who read it can also know them) and to start with a topic that is related to nutrition and eating.  I start with the secret to losing weight. 

Good Eggs and their approach to fostering locally produced food reminded me that the secret to losing weight is as much about how you eat, as it is about what you eat.  Because, the best, safest, healthiest way to lost weight is (a drum roll please) 


I understand that some of you may be underwhelmed by this secret however it is much more profound than you may think.  By changing how you think about food, by actually thinking in terms of the quality of the eating experience and the quality of the food you eat, it is extremely easy to eat less.    While our culture encourages a “more is better” supersized attitude, the fact is that food tastes better when eaten slowly, when savored and when appreciated in a deeper almost spiritual manner.  When you eat that way, you tend to eat healthier foods and to eat less. 

In most religions, food has a spiritual place.  In Judaism, which I practice, there are specific prayers to be said before eating or drinking anything, the gist of those prayers being to thank God for the food.  When these prayers were written, you ate food after you or someone you knew actually produced it.  It was highly personal and part of the social fabric in which you lived.  It was only natural to thank God for all that went into what was before you on the table as it was readily apparent that the food did not just appear and that you and others you loved worked hard to put it on the table.   In today’s world, we have moved towards anonymity of the food producers.  We just go to the supermarket and ignore the work, sweat and pride that people who produce that food take.  We sometimes cannot even recognize the food as food as it is so processed and packaged that it becomes a product rather than something that came from the earth or from an animal that was slaughtered (hopefully humanely as both kashrut in Judaism and halal in Islam encourage) so that you can thrive.  However, when you stop before each meal and take a moment to think about all that when into the food, and thank either God or the people who produced it, or even the food itself as some have suggested, you actually eat slower, eat less and naturally follow a major aspect of the secret of weight loss. 

This attitude towards food also can force you to never eat on the run, eat standing up, or eat in a car, all of which can lead to eating more and gaining weight or maintaining higher weight.  That rushed approach to eating can never acknowledge all that goes into the production of the food and can often be based on eating products which are made to be eaten in that manner rather than eating food.  The approach of food as something to be slowly savored leads to less eating and more weight loss.  In our world, food research historically has been rightfully focused on feeding more people at less cost.  In other words the research has been focused on quantity which from a world hunger prospective makes perfect sense.  Local food in contrast is often developed for quality rather than quantity with local food producers focused on organic farming methods, taste and nutritional value rather than cost and quantity. 

Thus how you eat becomes even more important than what you eat as long as you are eating, as MichaelPollan has wisely stated, food rather than packaged items that you cannot recognize as food.  When you purchase food that is locally produced, since it does not need the same additives to increase product longevity as food created at a distance needs, you know and can easily recognize it as food.  As natural flavors are brought alive you don’t need the flavor that comes from the added sugars and other artificial flavors that processed foods bring to you and that can lead to weight gain.  When that first bite is savored, you often want to eat more slowly as you actually taste every bite.  Do this and you do eat less. 

Exercising more is also part of the secret.  This should also be done as a part of your life and not as a sprint to a finish line of less weight.  Just move more than you currently move and work up from there.  Start by parking further away in the parking lot, taking stairs instead of elevators for one or two (maybe even three or four) floors, pacing while talking on the phone instead of sitting.  From there, find something you like doing and dedicate time to yourself to do it.  Create your own escapes and small strategies to move more and let your activity increase from there.  One of the other parts of this secret is that the more you move, the less hungry you will be.  There should never be a finish line, although you may have goals along the way.  I believe the goals should not revolve around your weight.  They should revolve about changing your life and the way you approach food and activity as part of your life. 

Your goals should focus on ways to permanently make yourself happier.  None of these secrets involve a “diet” or a Biggest Loser approach to training that most people with work, family and other obligations will never have the time for.  Instead it is all a way of giving more time to your own needs as part of your everyday life: making this approach a part of living, not a part of dieting. 

I will now admit that I did not always follow my own secret as stress and time worked to undermine my own knowledge.  But I am now doing this, and have lost almost thirty pounds and feel infinitely healthier and happier.  It may be hard to change, but when the main change is just to pay attention to your own real needs in terms of food and activity, it feeds (pun intended) on itself and just gets easier and easier.  That too is part of the secret. 

Thursday, July 12, 2012

Physicians, Ethics and Costs

Physicians, Ethics and Costs

A thoughtful article in this week’s New England Journal ofMedicine entitled “Centsand Sensitivity — Teaching Physicians to Think about Costs” by Lisa Rosenbaum, M.D., and Daniela Lamas, M.D. is an interesting perspective on the culture of medicine which rewards and emphasizes, completeness of evaluation weighed against the societal need to lower costs.  They ask the important question,

“Is there a place for principles of cost-effectiveness in medical education? Or does introducing cost into our discussions threaten to destroy what remains of the patient–physician relationship?”

Their answer is that cost should play a role however the examples they give make it clear that the costs to the individual are the important factor and not necessarily the societal costs.  They quote Dr. Martin Samuels of Boston’s Brigham and Women’s Hospital as stating:  “when physicians start weighing society’s needs as well as those of individual patients, they begin to lose the essence of what it means to be a doctor. When we lose our personal responsibility to individual patients, he says, ‘We are in deep trouble.’”

It is important to understand just what is being discussed and in many ways, I strongly agree with the statement by Arthur Caplan that they site, “The fight about cost is a smokescreen,” says Caplan. “What’s really at issue is the definition of ethical physician advocacy.” 

Health professionals who care about patients need to care about the person and not only the patient.  Caring about a person means understanding them as an individual and not only as an organism with a disease.  A person’s economic health is a part of their personhood just as is their psychological health, their family connections, their spiritual health and their work.  Cost is an important factor to many people but it is not necessarily more important than the other pieces that make each of us unique. 

The article does understand that the cost to the individual is the important consideration finishing with the statement,

“Now some educational reformers are offering us an added ethical incentive.  Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm.”

Just to emphasize the point.  A health professional caring for a person should always think about the costs to that individual, financial and otherwise and should never think about the cost to society when it conflicts with the good of the individual.  That is the true essence of being a care giver and is the true essence of being a Health Assistant.  Of course the irony of that ethical imperative is when you act in that manner, focusing on the needs of the individual, the result is that the costs to society as a whole are decreased significantly.  That is also the strong lesson that we at Accolade have learned.  

Saturday, July 7, 2012

Good Healthcare is a Symphony

Good health care is like a fine symphony.  Different professionals and different skills must work in concert to create a result that is much bigger than the individual components.    Here are two versions of a well-known anecdote in the classical music world that has been repeated in many versions over the years.  It tells the story of an efficiency expert enlisted to investigate a symphony orchestra.

Version 1

 He reported: "I found hidden unemployment. At least seven employees played the very same movements, on violins, throughout an entire piece.  On the other hand, the employees in the wind and percussion sections sat through extended periods of a concert without moving a muscle or playing a thing. I also discovered there were entire parts that musicians played over and over, for no reason.  Most of the employees appear to be unskilled as the management has to employ a man, full-time, to wave his arms around and signal to them what to play, when to stop, at what speed, and even at what volume.”

All of this, forced the efficiency expert to come to the conclusion an orchestra is a wasteful institution; it is neither efficient nor profitable; its output may be categorized as "arty and impractical".

Version 2 – A specific report on Schubert’s Unfinished Symphony

  1. For a considerable period, the oboe players had nothing to do. Their number should be reduced and their work spread over the whole orchestra, avoiding peaks of inactivity.
  2. All 12 violins were playing identical notes. This seems to be unneeded duplication, and the staff of this section should be cut. If a volume of sound is really required, this could be accomplished with the use of an amplifier.
  3. Much effort was involved in playing the 16th notes. This appears to be an excessive refinement, and it is recommended that all notes be rounded up to the nearest 8th note. If this were done, it would be possible to use para-professionals instead of experienced musicians.
  4. No useful purpose is served by repeating with horns the passage that has already been handled by strings. If all such redundant passages were eliminated then the concert could be reduced from two hours to twenty minutes.
  5. The symphony had two movements. If Mr. Schubert didn't achieve his musical goals by the end of the first movement, then he should have stopped there.

In light of the above, one can only conclude that had Mr. Schubert given attention to these matters, he probably would have had time to finish the symphony.

Why do I relate these stories in a discussion of health care?  

In many ways, the move to managed care has been told by these anecdotes.  In the move to make health care more affordable, which is a wonderful goal as it increases access to health care, we have tried to make individual doctor visits more efficient and we have succeeded.  Unfortunately, much of the richness of the physician leading a team and coordinating an effort with the goal of creating a wonderful result greater than the individual pieces has been lost in the process.  As physicians are not rewarded for coordination and in many ways are even discouraged financially from working together the doctors become nothing more than technical experts in their own scientific fields.  Even family physicians who are supposed to be the paradigms of ongoing coordinated care, are unable to do all that needs to be done to assist, coordinate and support those traveling through the complex medical system.  Instead they are expected and trained to see large numbers of patients per day with “simple” illnesses and to triage those who are sicker to specialists. 

But in our complex medical world, there are no simple illnesses.  Every illness has emotional, financial, and social factors.  The mother with small children and limited income who has asthma and needs a chest x-ray and pulmonary function tests needs to understand how to pay any copayments and be able to afford those co-payments, needs a way to schedule the tests, needs a person to watch her children while she goes for the test, and needs help understanding the risks and benefits of the medications that she will have to purchase and take.  She needs someone to help her find the way to communicate all this to her family, who depend on her, and needs help dealing with the stress and fear that accompanies it.  Yet we now have no concert master or conductor.  The primary care doctor has no time, and is not paid to do all this.

I am enough of a traditionalist to believe that a good physician should make the best “conductor” of this symphony although I also know that strong health professionals trained in other disciplines such as nursing, psychology and social work can also play that type of role. It is less a matter of formal degrees and more a matter of communication and coordination skills and resources.  In the best of all possible worlds, a doctor would team with a professional communicator/coordinator/supporter (in Accolade terms a Health Assistant) to give the patient the best chance of having health care that resonates as a fine symphony.  A doctor would then be able to still be relatively efficient while giving the patient everything he or she needs. 

We need both scientific medicine and a symphony like beauty and elegance in the delivery of that medicine.  Until that happens, managed care, of which I am a part, will capture efficiency at the expense of truly caring for those in need.  Here at Accolade, we are committed to providing the humanity that everyone needs in a way that creates cost savings while enhancing the important element of caring.  

Wednesday, July 4, 2012

The Cost of Hope

 “The Cost of Hope” by Amanda Bennett is billed as “the story of a marriage, a family and the quest for life”.  This excellent book describes Amanda Bennett’s journey through life together with her husband who died of cancer after a long illness.  While Amanda Bennett, a well-known journalist, in part focused the book on many of the problems of high costs and poor communication that confronts families when someone they love is sick, I read it more as a love story than a commentary on health policy.  It is a moving tale of the support she gave her husband and he gave her, when he was faced with a rare cancer with no curative therapy.    It is above all a book about life and a book about the true love that drives people to acts of heroism when faced with disaster. 

When I read this book, I think of all the people I come across professionally who go to work, raise families, and help those closest to them with challenges that the rest of us can only pray to avoid.  The mother of the two year old child who has been sick since age 6 months with a rare illness who lives in a small town in the south and whose husband earns a wage that is not much more than the poverty level comes to mind as one example.  She does not work outside of the home in order to care for her child and has become an expert on this unusual disease, knowing much more than most physicians.  She travels long distances for his doctor’s appointments and communicates with experts around the country via email.  She is also an expert on state, local and federal regulations having to do with care of children, disability issues and other resources.  This woman is a true hero.  Or the business executive I know who has put her career on hold while she cares for her sick, elderly mother who suffers from constant pain.  She is a fierce advocate for her mother, using all of her business skills and her negotiation skills to make sure that the health professionals coordinate and communicate with each other and that her mother never gets caught in the bureaucratic nightmare that Medicare can be. 

When we talk about health care costs, health care policy and health care delivery, we are really talking about people often fighting for their lives, supported by the heroes who love them.  We talk about people showing courage in the face of illness and adversity.  We are talking about individuals and their families finding their way through a complex system of medical opinions which are often contradictory, insurance policies which are often incomprehensible and laws and regulations designed for population and budgetary reasons and not the care of the individual.  We see people taking their and their loved one’s illnesses as a chance to elevate themselves beyond the illness and into a type of nobility of sacrifice and focus. 

Amanda Bennett captures this and by telling her and her family’s story, moves the discussion of health care, which is often mired in partisan political attacks from all sides of the political spectrum into the deeply personal story it is for all of us. 

At Accolade, we are truly fortunate to have found another way of helping people and also addressing some of the cost and quality problems that are part of health care.  We are privileged to be helpers and observers of the heroism of people and their families and to find ways to cheerlead those heroes while also assisting them in their quest for quality care with a strong dose of humanity.  There truly is no better way to make a living and I am thankful every day for what we at Accolade all do. 

Sunday, July 1, 2012

Process and Thought Reprinted from Google Plus post

Process and Thought
The big news today is the announcement by the Supreme Court of their decision on the Affordable Care Act (ACA) or ObamaCare as it is referred to.  I write this before knowing the result of that decision and while certainly important, whatever the decision is a person in need will still need a thinking, caring professional to care for them and be with them when they are in need.  For me, the more interesting story this week is the story of two children in Tacoma, Washington who were severely sunburned when a school official would not let them use sun block when they were on a school outing.  The school officials were following a law and a process dictated by that law that did not allow the use of sun block by children without a written prescription by a physician. The school officials in question, by following the policy and process in place insisted they had done nothing wrong.  At the same time, the children were subject to severe sunburn that, in the case of one of the children, was dangerous in that the child had a form of albinism and extreme sun sensitivity.

  Whatever the decision made, our health care is influenced and defined by laws, policies, procedures and statutes. While the laws may change, their presence is a constant.  While laws and procedures are usually put into place with the best of intentions, the consequences of those laws are often unexpected and may be counter to the intent of the “rule makers” whether they are legislators or managers.

The fact is that laws, procedures and statues all can have unintended consequences.  The state legislators in Washington State truly thought they were protecting children from possible allergic reactions to elements of sunblock when they passed that law.  The school officials truly felt that they were being good education professionals by following the law.

 In a recent web first article in Health Affairs, Mary Naylor of the University of Pennsylvania and her co-authors looked at some aspects of the Affordable Care Act (ACA) that are designed to improve transitional care and prevent readmission to the hospital.  The authors found that the incentives built into the act to encourage hospitals to lower readmissions, could instead encourage them to limit access to people with multiple illnesses who are at most risk for readmissions.  The authors also pointed out that the bundled payments that are part of the national pilot program do not include long term care so that the health systems involved could withhold services and “push” them into long term care to create improved finances.  A third part of the ACA calls for community based care transition programs however access to these programs require a hospitalization and often people can be very ill with multiple illnesses but not require hospitalization.  Thus many of those in need would not be eligible unless they were hospitalized which could increase hospitalizations as caring physicians admitted people to help them gain access to the program elements.

The fact is that health care is broad and involves more than just isolated illnesses, insurance contracts and laws.  Health is psychological, social and spiritual. A specific illness or issue is rarely found in isolation but is part of a person who has a unique set of genetic material and unique biologic characteristics often including other illnesses.   Health is a family affair that affects people beyond the patient. Thus no rules, laws or procedures can address every possible person and every possible issue. Thought and judgment are needed by all health professionals and not only rules, policies and procedures.  No matter what the rule or law, a school official should never allow a child to be in danger from the sun, and a health professional should never let a law dictate an intervention that can cause harm or prevent an intervention that can help one in need.  
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Unintended Consequences Of Steps To Cut Readmissions And Reform Payment May Threaten Care Of Vulnerable Older Adults »
Abstract The US health care system is characterized by fragmentation and misaligned incentives, which creates challenges for both providers and recipients. These challenges are magnified for older adu...

ACA and the Supreme Court Reprinted from my Google Plus post

ACA and the Supreme Court
Many people have asked my opinion of the Supreme Court decision concerning the constitutionality of the Affordable Care Act.  While I am flattered to be asked, I am also a little confused as my knowledge and experience is in health and not in constitutional law.  So rather than even try to comment on that decision, I will share some of my thoughts on the ACA now that it is clearly the law of the land. 
The ACA is a complex, multifaceted piece of legislation that is over 2,000 pages long.  That fact has been well discussed.  Another aspect of that complexity is that a law is only a starting point.  It is the start of a process that results in the Executive branch of government writing the procedures, requirements and other details of how that law will actually be carried out.  It is said that for every page of legislation that is written, about 100 pages of policies and requirements need to be written in order for the law to be carried out.  Thus, we now have hard working, and well-meaning Federal employees developing these details which could easily total 200,000 pages even as the debate goes on.  Until they are written and then followed, we will not truly understand the full impact of all the different pieces of the law as passed.  That, in general, does worry me. 

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was passed as a way to better ensure that people’s privacy was protected while in the health care system.  For many, it has been translated into forms that people sign without understanding what they are signing and has led to less communication with family members even though communication is critical when you or a loved one is ill.  The intent of the law was, and remains, wonderful.  The way it is carried out by health care professionals and facilities and by the government agencies that must police it, protects the health industry and make the bureaucrats jobs easier, but does not necessarily help the patient’s privacy.  I do not blame the health professionals or the federal employees.  They are following the logical steps to implement and enforce a law.  The law just places health professionals and facilities in a very difficult place in which they must prove that they are doing what is required and places federal employees in an equally difficult position of having to prove to Congress that they are effectively making sure that the law is in place and working.  Thus the goals become the process rather than the problem of privacy that the law was designed to address. 

That is the lens I have on when I read and review the ACA.  There are wonderful aspects to this law, many of them involved in insurance reform.  As someone who has been in the health insurance industry in one form or another for many years, I am thrilled to see the end of pre-existing condition limitations.  I am also thrilled by the end of lifetime maximums for large, catastrophic situations.  I am more bothered by some of the parts of the legislation that potentially interfere between a doctor and a patient.  In medicine, standards are critical and accountability of health professionals is also critical however the individual variability in patient care is so great, that accountability cannot and should not get in the way of the relationship that must form between a doctor, a patient, and often a family.  The Independent Payment Advisory Board is a 15 member board of experts who will decide on Medicare spending without oversight, including without Congressional oversight.  This worries me.  While I believe it would be well meaning and would focus on the population’s needs, it would not see the individuals behind the population statistics.  Experts are never experts in the care of individuals that they do not know and do not see.  They base their pronouncements on studies, statistics, and academic debates.  If you or a family member is sick, you want your care to be informed by experts but carried out by a caring professional who knows you and your desires and needs.  In many ways, when we pass laws that attempt to define very specifically how individuals should be medically treated, we enter into a dangerous place as the actual practice of medicine, and the care of those in need, is rarely specific and is filled with judgment calls that are different from person to person. 

I have spent a good part of my career trying to reconcile the shades of gray that are medicine to the black and white of laws and finances.  After doing this for more than twenty years, I have finally come to the conclusion that they can never be completely reconciled and instead must live together in a shaky balance.  Laws and finances are needed but there must always be room for deviation when an individual need does not fit the law or the circumstance.  This does not mean breaking a law but it does mean understanding when a law may not apply.  The ACA contains detailed provisions that can potentially be harmful to an individual’s care when it attempts to create false clarity in health decision making.  More often, the decisions are based on different balancing of the risk and benefits (and yes – costs) and are influenced by family, culture, religion, and other individual factors that no board can ever take into account. 

Another aspect of a law that is this big and this expansive is the unintended consequences.  I do worry that as the Advisory Board cuts Medicare spending, that fees for physicians will go down dramatically.  We already have a situation in which doctors are spending far too little time with patients to give the type of quality of care that is often needed.  When unit fees for medical services go down, physicians react in the very human way of increasing their volume of services.  This is not a defense of doctors receiving large sums of money nor is it an indictment of physician greed.  It is an acknowledgment that doctors are also people who have their own needs and desires.  They are usually caring smart people and we have to be careful not to put impediments in their path.  As incomes for physicians go down, and the satisfaction with the career goes down due to less time spent with each patient, the quality of people choosing medicine as a career may also go down.  This is but one example of a potential unintended consequence.  In a recent Health Affairs article, authors from the University of Pennsylvania discussed three other examples from the ACA of parts of the law that may not turn out as desired.  I discussed that in a piece I posted just before the Supreme Court decision. 

So we have taken a complex system and possibly made it more complex with ACA while also improving some aspects of the health insurance industry.  The fact that we will be covering more people is a strong plus.  The challenge is that we need caring, independent professionals who are not focused on the population but on each of us as individuals to diagnose and treat our ailments and care for us..   I fear that the law as written may be a step backward in that very personal aspect of care.