Monday, October 21, 2013


There are victories of the soul and spirit.  Sometimes even if you lose you win.

                Elie Wiesel

It is amazing how victories can be small – even invisible to others – and can manifest in the darkest of situations and times, and yet still have a major impact.  This past week, that truth was brought home to me yet again, as I shared a stage with a number of very prominent women leaders in health.  I was fortunate enough to be part of a panel discussion at the Women’s Healthcare Innovation and Leadership Showcase sponsored by the Metro (NY/NJ/CT) chapter of the Healthcare Businesswomen’s Association .

On that panel were very smart women who are passionate about changing the world of healthcare. Two, in particular, spoke forcefully and eloquently about the seemingly small, individual efforts that—when multiplied—can change the world. 

Dr. Julie Gerberding, President of Merck Vaccines and the former Director of the Centers for Disease Control, spoke of scrubbing toilets in a small African village and realizing that clean water and empowered mothers in this village could change the world.  She talked about women who had nothing finding ways to fight cervical cancer by working together with community support.  In the midst of the poverty and squalor of a small village in Africa, Dr. Gerberding saw hope and strength in the women she met and worked with. 

Dr. Anne Beal, Deputy Executive Director and Chief Operating Officer for the Patient-Centered Outcomes Research Institute, remembered a poor single woman, who—upon discovering she was pregnant—spent weeks and weeks fighting her way through the system to obtain Medicaid coverage so she could receive the right prenatal care. Finally, at 24 weeks of pregnancy, she saw the doctor for the first time—and discovered she was carrying triplets. Dr. Beal spoke of that woman’s great strength, and of her ability to obtain care for herself and for her new family when she delivered prematurely. In a situation that some would find hopeless, Dr. Beal and that brave mother saw triumph. 

In both of these leaders’ stories, I could hear the satisfaction and joy each had in helping these women in the worst situations achieve small victories.  We were not talking about dramatic lifesaving surgery, but rather about the commonplace issues of clean toilets, routine exams, and Medicaid coverage. 

And the entire meeting was energized by their work and their words.  These moving stories made me think about my own personal journey and the fact that I was most inspired by playing a small role in helping someone find the “victories of the soul” as described by that great writer, Elie Wiesel.   While I was in college, I taught guitar to children with brain injuries. My talent at guitar was such that I could only teach someone who had physical disorders of coordination (which is why I am not playing guitar on stage these days, but talking instead).  When I saw a child’s satisfaction at mastering a note, I did not know that I was working to change the world, but helping those young people master motor control and gain confidence was earth- shaking. 

My sister has recounted her own experience as a special education teacher, helping a small child in a wheelchair at Halloween.  That little boy—dressed in his costume—came to her class in his wheelchair for their Halloween party.  He was so excited about the costume! When my sister greeted him and told him what a great costume it was, he asked, “How did you know it was me?”  He was not, at that moment, a sick child confined to a wheelchair; he was just a kid in a costume acting like any other kid. 

When I was in practice, I often treated patients who were terminally ill.  I was given the privilege of being with people at their time of greatest need, sharing their fears and their hopes, helping them communicate with their families, and helping them feel valued and heard by those they cared about in their last days and hours.  The victories I saw as they spent their last days with those they loved were inspiring. 

My wife (a specialist in clinical genetics) helps parents every day whose baby is born with a severe genetic illness, often terminal, as they struggle to accept that reality and create new hopes for their child—if that child survives—and for future children.  When she sees an older child with severe disabilities and greets the child playfully—as a child and not as a “specimen” with severe impairments—parents understand that she sees their son or daughter as a unique person.  Those are huge victories for the entire family. 

Good, experienced clinicians —and health policy leaders like Drs. Gerberding and Dr. Beal--know this secret almost instinctively: When you help people achieve small triumphs, victories of the soul and spirit, you help them achieve higher quality care—and you also save money for the entire healthcare system.  When that villager is able to help her community get clean water, the entire health of the community improves.  When the mother of triplets can advocate for herself in the confusing and difficult systems of healthcare and health benefits, the care her children will receive is better, and the chance of those triplets ending up in the hospital for prolonged stays drops dramatically.  When the family of a terminally ill child is able to avoid unnecessary, often uncomfortable tests and procedures--and the parents can hold their baby for those last precious hours instead, it is better for the parents, the child and the healthcare system.

At Accolade, I am privileged to have helped build a system that helps people every day in small ways. We help people get those small victories every single day—the victories that allow them to improve their health, live their lives, and maintain autonomy over their own bodies and their own decisions.  I get to play a part of the interactions our Health Assistants have daily. I know that as we help each of those people in small ways, we are changing their individual worlds and helping the broader health system and community, as well.   



Monday, October 14, 2013

Bad Habits or Critical Thinking?

Danielle Ofri, a physician at NYU Medical Center (in New York City) and a New York Times contributor, is one of my favorite medical commentators. Her insights and judgment into issues such as the use of the medical narrative are impeccable. However, I wonder if in this recent opinion piece she might have missed the mark a bit.

In this article, she takes herself to task for a “bad habit” of not following the ‘Choosing Wisely’ guideline from the Society of General Internal Medicine (SGIM) concerning routine visits. She still sees her patients routinely for health checks, even though this particular SGIM guideline states “Don’t perform routine general health checks for asymptomatic adults.” The guideline then goes on to explain:

 “Routine general health checks are office visits between a health professional and a patient exclusively for preventive counseling and screening tests. In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management, such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause including the ‘health maintenance’ annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.”

And yet, while Ofri considers her own actions to be bad habits, I consider them good critical thinking—and good instincts. I believe this “bad habit” is really related to a deep understanding she has of the doctor-patient relationship—an understanding not reflected in the guideline.

While this guideline (and the many others that accompany it) is well-intentioned and an important step toward making us all wiser doctors and patients, it’s also important to think critically about it.

The guideline is based on scientific studies of populations and the population effect on reducing morbidity, mortality and hospitalization, but it doesn’t take into consideration other studies that have documented the eroding trust in physicians, as well as the studies that document the morbidity increases resulting from lifestyle diseases.

I find it difficult to separate these two issues. Patients must trust their doctors if they are to follow doctors’ advice concerning lifestyle, as well as the more immediate advice doctors give suggesting diagnostics and therapeutics. If patients are going to take medications as they were meant to be taken or undergo a diagnostic test that will ultimately help them better, they must have a relationship with the physician built on trust. That kind of relationship only happens when the doctor gets to know the patient as a person—not just his or her physiology and health risks—and that requires regular contact between a doctor and an individual.    

In today’s world, it is more important than ever to think about what happens outside of the doctor’s office as well as what happens inside it. Before the person ever sees the doctor, how does he or she decide whether to go in the first place? It often depends on how much trust a person has in that doctor—and how much value he or she thinks the visit will offer. In an absence of trust, a person may not even go to the visit—and miss an opportunity for early treatment.  Or, when that person leaves the office, will he or she act on the physician’s advice?  What if the physician wants to try “watchful waiting,” which requires a great deal of patience and confidence in that guidance?

We should ask ourselves if the guideline’s goal should also be related to trust. Shouldn’t trust be at least as important as the epidemiology of a borderline cholesterol level? Perhaps the real benefit is not just in treating that borderline cholesterol, but comes home to roost 1 or 2 years later, when—in an urgent situation—the person actually calls the doctor he or she trusts.

Many years ago, I ran a nutritional support service and made regular home visits to the patients we treated. I found I learned the truth about what patients were really doing when I went to their homes. I learned about the real-life barriers that prevented them from following the advice I gave. I formed a bond with them that was related to my willingness to meet them where they were, not just emotionally, but physically.

In healthcare, we are beginning to recognize the importance of shared decision- making—in which the doctor and the patient jointly decide the best course of action. This can only occur with trust. It only occurs when the doctor knows the person, and not only the patient. It only occurs when the patient believes the doctor has his or her best interest at heart--and not the best interest of the health system they work for, the government, or even society as a whole--no matter how “noble” that may seem from a population perspective.  

Perhaps we could modify the Choosing Wisely guideline so that we avoid lab tests at those yearly visits, but maintain the yearly visit itself to help maintain the bond? Perhaps it should even be a yearly home visit (although I suspect that would not be warmly received by most doctors or health policy people) to really see all that the patient and the family unit has to deal with in order to try and stay healthy?  A modification in the guideline that fostered trust and relationship building could result in better care and even more cost savings.

I applaud Dr. Ofri’s instinct to follow her own path, rather than following the guideline in this case. Her voice will help SGIM and all those involved in setting guidelines better understand that healthcare needs trusting relationships as much as it needs science and epidemiology. I hope that she continues to use the critical thinking skills that are reflected in so much of her writing to build trust and motivate patients so they call when they are in need--and follow the sage advice I am sure Dr. Ofri gives.

Monday, October 7, 2013

Trust, Small Decisions, and Improving Health Care

Our lives are built on trust in others. We trust that the person in the car stopped by the red light will not suddenly hit the accelerator and run us over as we cross the street. We trust that the people upon whom we depend, whether they are family members, doctors, grocers, or plumbers, will do their jobs and meet their responsibilities in such a way to help us stay healthy, fed and safe. However, in an increasingly impersonal world, can we still trust? Can we depend on the right things happening, when we don’t know the nurse, the doctor, the plumber and the grocer?

I grew up the son of an immigrant who owned a small “mom-and-pop” grocery store in New York City. My father knew each of his customers, would physically give them the food, and would understand when they couldn’t pay at that moment in time and would try to help them. I vividly remember seeing lists of names—on the backs of envelopes and scraps of paper in the store—of people who owed money from when they needed food and couldn’t pay for it. My father felt he had a responsibility to his customers who needed the food; the fact that they couldn’t pay at that moment, he reasoned, should not stop them from having that food. There was no interest paid or collection agencies. There was simply trust. Sometimes, I would deliver the food to people’s homes when they could not leave the house because they were old or infirm. As a child, I was sometimes a little frightened going into strangers’ apartments in areas of New York that others would consider dangerous. Yet that, too, grew out of my father’s sense of responsibility—and the trust between my father and the people who needed the food.

So what does all this have to do with health decisions? Health is not only about what doctors, hospitals, or any healthcare providers decide. It is about the small decisions people make every day in thousands of ways, big and small. Here at Accolade, we tried to estimate the number of health decisions individuals make every year. We started with claims, as each claim represents a medical service that results from a decision. We added in over-the-counter medication use, gym use, and other “everyday” activities. We left out the decisions around food purchases--even though as a grocer’s son and a physician who is board certified in clinical nutrition, I believe food purchases to be among the most important health decisions. We also left out the decisions we all make around everyday activity, such as whether we park our car in a place far from our office entrance or as close as we can to avoid a long walk. The result: We estimated that the average person makes more than 2,500 health decisions a year. It is, admittedly, a poor estimate-- probably underestimating by a large factor; it also reflects the average person, not necessarily the sick person.

How are all these big and little decisions related to trust? If you want to improve healthcare decision-making, you have to be able to influence those thousands of small decisions—which means you must build trust with the decision-makers, who may or may not be the patient. In many families, the wife and mother is the main decision-maker for the family. It also means that health systems and health policy must support and facilitate good decisions by people even when those decisions are small, whether they are healthy or sick.

Let’s examine nutrition as an example. A recent Health Affairs article about nutrition highlighted the health consequences of an industrialized food industry that processes food—sometimes to increase affordability, sometimes to increase shelf life, and ultimately leads to obesity which leads to disease. Written by two former Secretaries of Agriculture, Dan Glickman and Ann Veneman, the article states:

On the one hand, with obesity-related health costs rapidly rising, the federal government has encouraged people to make healthy dietary choices through efforts such as Let’s Move! and MyPlate. On the other hand, the federal government spends billions of dollars on traditional agricultural commodity programs that fail to reinforce the kind of healthy dietary choices outlined in federal dietary guidelines.”

This article was published at about the same time Sequoia Capital invested in a rapidly growing start-up company, Good Eggs.  Good Eggs is making locally sourced healthier food more available, offering a communication platform and delivery service for consumers with the farmers, bakers, and other food providers that is personal and easy. (Full disclosure: My son Rob Spiro is co-founder and CEO of Good Eggs; my goal is to someday bag and deliver groceries for them so I can go full circle from my youth.)

Good Eggs realizes that the answer is less about programs and more about fostering a personal system in which the local person who advises people and helps them is right there, helping them make better decisions. We need to replace the emphasis on an industrial system that is focused on large production and bulk delivery. We need to foster a trust based on the fact that you know the person who produces your food, that they know you and that you each have the other’s best interests in mind. You meet your local farmer on Good Eggs, can speak to him or her and end up eating healthier foods as a result of that personal trust. This trust, simplification and facilitation of smart, small decisions leads to better eating, lower rates of obesity and lower healthcare costs than any forced weight loss program. It is really about trust and people-to-people communication.

Technology can help facilitate this communication, but can never be the only answer. The folks at Good Eggs have found that they had to use creative and imaginative apps and technology, but that they also had to deliver the food and actually “touch” their customers, person to person. Bryan Shreier from Sequoia Capital in an article linked here talks about the need for tech firms to embrace operations and not assume the tech alone will be the answer. He uses the examples of Good Eggs, as well as Uber, the limousine service, as companies using technology to simplify and personalize a human interaction.

In healthcare, specifically, that need to facilitate the person-to-person interaction, which leads to better decision-making and better health and sickness care is even more urgent—and is our approach at Accolade.

Unfortunately, the health technology industry often seems to only focus on the "big data" and the “apps.” In an article in Fortune Magazine entitled, “Health Apps Don’t Save People, People Do,”, Ryan Bradley reviews a number of studies that show, when it comes to the treatment of obesity and diabetes, apps alone--no matter how enticing and technologically simple--are never as effective as person-to-person interactions. Bringing people together with each other and with educators and professionals on a regular basis positively influences their decision-making, and ultimately, their activities and the choices they make.

At Accolade, we see that every day in the small decisions that our Health Assistants help people make as they live their lives. The people we serve are trying to make a living, feed their families, and choose what to do about their ailments and lifestyle. No matter how big or small those choices are, the answer always lies in the trust and help we give each other. That social interaction gives strength to our fellow  human being, helps them through tough times, shares and celebrates good times—and creates the positive decisions and outcomes that bring better health and better life to people. While we use "big data" and "apps", ultimately we know that Angry Birds alone can’t do that. We know that technology can only be the answer when it is facilitating human interactions.