The cost of medical care is poisoning us

According to Moore’s dictum (newly minted by me, although I’ve had the idea for a long time), appropriate medical care must meet one of three criteria: either it makes us feel better, it makes us live longer, or it saves us money. But these three criteria exist in a state of conflict. Chemotherapy certainly doesn’t make us feel better. It often causes hair loss, nausea, rashes, low blood counts, and other unseemly side effects, sometimes for months or years at a time. But we accept chemotherapy’s toxicity in exchange for a chance at a longer life. Ditto the discomfort and inconvenience of surgery. And some therapies that make us feel better in the short term may also shorten our lives (though, paradoxically, some hospice services may actually prolong life). 

Unfortunately, chemotherapy not only drains our energy level, but it is also likely to drain our bank account, and for modest life gains. New therapies for cancers often cost tens of thousands of dollars per month in exchange for an anticipated life prolongation of less than a year. That extra year may be precious, and I don’t mean to minimize it. But the cost adds up. For a drug costing ~$14,000 per month, a patient may have a copayment of ~$3,000 or more per month. Patients on Medicare, our national socialized medicine for elders, who are newly diagnosed with cancer incur out-of-pocket spending averaging 23.7 percent of their household income. Ten percent of Medicare folks with cancer have out-of-pocket spending equivalent to almost two-thirds of their household income. And for those of us not on Medicare, 40% of whom would not be able to find $400 in cash in an emergency, the cost is likely completely out of reach. So it’s no surprise that medical bankruptcy accounts for almost two-thirds of all U.S. family bankruptcy filings or that patients with cancer are 2.5 times as likely as non-cancer patients to file for bankruptcy. 

For many patients, this financial toxicity is as feared as the physical toxicity of the drugs themselves. One of my physician colleagues darkly refers to the medical-industrial complex as being in the business of “farming sick people for money.” Elements of cancer care seem to confirm his suspicions. Financial toxicity is a big enough problem that the National Cancer Institute devotes a section of its website to helping patients navigate it. 

We shouldn’t just care about the topic because of our humanitarian impulses. We should care about its second-order effects. Financial distress, or even the fear of it, is associated with delayed initiation of treatment, limited patient adherence to treatment, and abandonment of recommended treatment. This is horrifying, and it’s not limited to cancer care. Here’s a model of how it might play out in heart disease, where financial toxicity has similarly been linked to poor outcomes: 

Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions (nih.gov)

Many are calling for greater adoption of the Center for Medicare and Medicaid Innovation’s Oncology Care Model, which identifies care navigation and connection of patients to resources as core functions of medical practice. But in spite of research demonstrating clear value, not every practice has a care navigator because of the lack of a sustainable model for reimbursement.

A potential strategy that may meet the Oncology Care Model halfway is the use of “community health workers,” laypersons with an intimate knowledge of specific populations that may be served by a practice. If a doctor has a hard time connecting with recent Vietnamese immigrants in her practice, for example, a Vietnamese-speaking CHW who has knowledge of the religion and culture of the region from which the patients immigrated may be able to work with them on shared decision-making around things like transportation, diet, adherence to medications, and even end-of-life planning. 

[disclosure: the Kansas Business Group on Health has CDC funding related to increased adoption of community health workers]

Does your employee policy cover care navigation, or do you have personal experience with a community health worker? If so, we’d love to hear about it. If not, we’d love to help.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Precision Medicine and Me

In case you missed our excellent discussion on precision oncology with Dr. Fred Schnell and Dr. Quoc Truong this week, we thought we’d review what precision medicine means for the future care of your covered lives.

Had you been diagnosed with, for example, lung cancer ten years ago, your oncologist would have acted primarily on the visual description of the tumor under the microscope as reported by the pathologist. They would have described the tumor as either a “small cell” carcinoma (arising from “neuroendocrine” tissue), an “adenocarcinoma” (arising from glandular tissue) or a “squamous cell” carcinoma (arising from skin-like cells). Then your oncologist, depending on the size of the tumor and its spread outside the lungs to places like liver or bone, would have prescribed a regimen of chemotherapy and possibly radiation based on which broad category your tumor fit into. The chemotherapy and radiation would have had “toxicity” that limited its dose: things like nausea, a rash, low blood counts, or fever. You and your oncologist would have crossed your fingers and hoped for a tumor response.

If you were to be diagnosed now, though, as Drs. Schnell and Truong outlined, you would ideally have two crucial tests done before you ever received treatment. The first would be a “whole-genome” scan of the tumor’s DNA for specific mutations that might affect its response to specific drugs. One that was mentioned yesterday was a mutation in the epithelial growth factor gene. The second test would be another whole-genome test, this time from your blood, to see if you had any predisposition to cancer that might affect your response or your family’s risk for cancer. This would not only help you but would help your family members adopt early detection practices if you were to be found to carry an abnormal gene. The most famous of these genes, unrelated to lung cancer, are probably the “BRCA” mutations that increase the risk of breast and ovarian cancers.

Based on those tests, you would not necessarily receive the blunt, toxic chemotherapy that you would have ten years ago. You may receive one of those drugs, but the testing might indicate that you’d be a better candidate for much more precise, directed therapy, such as a drug that specifically targets the epithelial growth factor receptor or another gene mutation.

This genetic testing is not cheap. Whole-genome testing may run into the $3,000 or higher range. But given the astonishing cost of cancer chemotherapy and radiation, paying for this testing upfront seems to be a reasonable gamble if it means a less toxic, more precise, and potentially more effective therapy for a malignancy. We would love to explore this topic with you further. If you haven’t had a chance to dial into one of our oncology modules, please feel free to reach out, and we’ll get you signed up!

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Delphi for High Value Care

Can the Oracle of Delphi move us toward more high-value care?

Have you ever been in a meeting in which important decisions seemed to be made by or for the loudest voices in the room, even when you had a hunch that the secret consensus of the room was not in favor of the decision? If so, then you’ve been in a situation where the Delphi method would have helped.

In ancient Greece, Pythia was the high priestess of the Temple of Apollo. She was informally known as the “Oracle of Delphi.” The Oracle was consulted about important decisions throughout the ancient classical world, and her opinion was considered so valuable that Delphi was considered the center of the world. (I consider Byers, Kansas, my childhood home, the center of the world, but that fact has more to do with my robust self-esteem than it does with geographic fact or fiction.)

In modern times–the 1950s–the Delphi name was applied to a decision-making or forecasting strategy pioneered by the RAND corporation, a famous nonprofit policy think tank. (R ANd D; “research and development.” Get it?) Except this time, the decision was not to be made by an all-knowing oracle, but by the carefully considered and anonymous consensus of the group. They called it the Delphi method, and it is my favorite way to keep louder or more senior voices from always getting their way in meetings or organizations.

Here’s how it works:

• A panel of “experts” is convened, usually virtually or remotely, ideally with a diverse background but some technical expertise regarding the question at hand.

• Each expert is asked to make an anonymous judgement or prediction regarding the question(s).

• The participants remain anonymous, even through the completion of the final report, so that those who are more senior, more vocal, or more reputable cannot dominate the decision-making. (computers have obviously made Delphi much, much easier to facilitate than it once was)

This anonymity is also meant to free participants from any embarrassment about admitting error and to prevent the “bandwagon effect,” in which faddish ideas can become popular.

The experts’ initial answers to survey questions are collected, and irrelevant content is filtered out by a panel director. Then the survey and its answers are cycled back through the group so that others can revise their own opinions or forecasts. This process continues with a goal of gradually working toward consensus:

Wikipedia

This works for more than just complex decisions

Delphi has been adapted into “Wideband Delphi,” a technique in Scrum project management in which team members repeatedly, and anonymously, estimate the amount of time or work a project will take until they reach consensus. Then their wisdom is measured against the real-life velocity of the project to inform future estimates.

This is all prologue to what I really want to write about today, which is a solution for “guideline bloat.” Medicine, like many complex fields and like the field you likely work in, be it engineering, human resources, or accounting, continually develops and refines guidelines for use as tools to guide the screening for and care of specific illnesses. But medicine has a problem: there are too many guidelines, and they tend to encourage more care, not less. A well-known study estimated that a single primary care doc providing nothing but USPSTF screening and prevention recommendations for an everyday practice would need most of the day just for those, assuming no sick people ever came in the door. But an average primary care physician doesn’t just see people for screening and prevention, as you know. The average patient she sees has more than three problems or complaints.

So calls have come to prioritize guideline use, and some are saying that Delphi is the way to do it. In the last few weeks we’ve seen a demonstration (paywall) of how that might work. A team of investigators from several medical schools reviewed guidelines from the years 2011 through 2016 to identify “potential deintensification recommendations” in primary care medicine. That is, how can we take unnecessary care away from patients instead of adding more diagnostic work and potentially unnecessary therapies? They came up with about 50 possible recommendations and then reconfigured them to generate recommendations that 1) were actionable and measurable, and that 2) explicitly defined the deintensification action and which patients it might apply to. Then they convened a Delphi expert panel to review their synthesized evidence and judge the potential recommendations. The final work product of the panel was intoxicating if, like me, you’re the kind of person that believes that good medicine involves stopping as many treatments as you start. Here’s an example.

The original, pared-down guideline on colon cancer screening that was fed to the group of experts looked like this:

JAMA Internal Medicine

That’s a mouthful. But after a few runs through the Delphi machine, that word salad was chopped down to this:

JAMA Internal Medicine

That may still seem awkward and wordy if you’re not completely comfortable with medical jargon (FOBT is “fecal occult blood testing,” and FIT is “fecal immunochemical testing.” Enjoy your lunch). But to translate English to English, it just says that, in an average population, we should not repeat colon cancer screening very often unless past attempts at screening have been thwarted by too much poop in the patient’s colon for the doctor to be able to see through the colonoscopy camera. In other words, the health care system should not foot the bill for too-frequent cancer screening.

Two editorialists (paywall) write enthusiastically about the prospects for this kind of thinking about low-value care when low-value care is “driven by clinician behavior and a disjointed US health care system that pays for doing more, necessary or not.”

So two recommendations this week, neither of which have been run through a Delphi panel: 1) You should be using Delphi in your company if you’re not, especially if you have powerful voices that tend to dominate decision making. And 2) we should all be thinking about systematic ways like this to reduce the amount of low-value care being delivered by our healthcare system and paid for by our companies.

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This was a reprint of a blog post from KBGH.

Your Doctor Is Your Real Financial Planner

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

The last time you spoke to your financial planner, I suspect the first question she asked you was some version of “Where would you like to be in ten years?” Or twenty, or thirty. Maybe you told her that you wanted to have your house paid off, or to be out of debt, or to be retired, or to have enough savings to send your kids to college.

The last time you went to the doctor, though, I’m willing to bet your conversation was more…retrospective. Medical students are taught to use open-ended questions to initiate a visit, so he probably asked something like “What brings you in today?” And if you’re like most people your answer wasn’t “I want to make sure I’m happier and healthier ten years from now than I am today.” Instead you probably led with whatever complaint was bothering you that day: a rash, a sore joint, shortness of breath. This doesn’t mean you were doing it wrong. Doctors exist to relieve suffering, after all. The Hippocratic Oath states in part that “I will apply, for the benefit of the sick, all measures which are required.”

``Where would you like to be in ten years?`` isn't just a question that should come from your financial planner. It should come from your doctor, too.

But if you’ll allow the slight stretching of a metaphor, what if your interactions with your health care professional sounded more like your conversations with your financial professional? Because the person that is most in charge of your financial future may not be your financial advisor. It’s more likely your doctor. Here are some hard truths at the intersection of medicine and finance:

• Illness and injury are the number one cause of bankruptcy in the United States, contributing to almost two-thirds of cases.

• The risk of illness goes up as income falls, and more than two-thirds of Americans with incomes below $40,000 say they could not scrape together $400 in an emergency.

• Medical debt is the number one reason to get a call from a collection agency, and a sixth of Americans have an unpaid medical bill on a credit card.

• One-third of cancer patients have to ask friends or family for money to finance their treatments.

• Health insurance does not necessarily protect against catastrophic loss of savings if you get sick: the ACA, for all its good, did little to reduce medical bankruptcies.

• And the expense of medical treatment may actually make outcomes worse. Filing for bankruptcy is associated with a 79% increase in the risk of death in patients with cancer.

So “Where would you like to be in ten years?” isn’t just a question that should come from your financial planner. It should come from your doctor, too.

What if we applied a financial planning rubric to health and wellness? Once the shock wore off from your doctor asking you where you wanted to be in ten years, what would you say? If you were diabetic, you might first answer that you wanted to avoid the complications of diabetes: you wanted to keep your vision, you wanted to keep all your toes, and you wanted to avoid having to go on dialysis for kidney failure. These are all perfectly good answers, but they suffer from low expectations. They’re a little like telling your financial advisor that you want to avoid bankruptcy and avoid having the bank repossess your house.

What if you were more ambitious? What if you said that, in addition to all those, you wanted to run a 5k with your granddaughter, or dance at your son’s wedding without being out of breath? What if you said you wanted to be able to carry your infant grandson up and down stairs without fearing a fall? Fortunately, just as the best financial strategies tend to be simple, the best health strategies are simple, too. Just as the financial advisor would hopefully come up with a plan to start putting money away, your doctor would work with you to make a shared decision on how to get to the last dance at that wedding a few years from now. The financial advisor might tell you to maximize deposits into tax-deferred annuities, while the doc might work with you to start scheduling “deposits” of physical activity. Just as your financial advisor might tell you to knock off the daily trips to Starbucks, your doc might tell you to knock off the bright screens in your eyes for an hour or two before bed (and, hopefully, would tell you to take it easy on the #PSL).

The next time you have a meeting with employees about their health benefits, ask them what they think of this philosophy. After all, the Hippocratic Oath also says, “I will prevent disease whenever I can, for prevention is preferable to cure.” And more powerfully, “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.”  Also remember that as an employer, you have the opportunity to help your employees stay healthy by offering real food at work instead of processed foods, providing a wellness program in a box, or by helping to shape the environment in which your employees live.

Examining Executive Physicals

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Fifteen years ago it was common to see parked semi trucks with CT scanners in the trailer, advertising “whole-body CT scans” as a preventive measure. Thankfully the trend eventually petered out. I can’t find reliable information on why the practice died. It’s possible that the worried segment of the population simply all had their CTs done, and no one else was willing to pay. But from a medical safety perspective, I hope the practice died because people–patients, regulators, or others–decided that the risk of “false positive” tests, with their necessary biopsies and follow-up testing, all of which carries its own risk, was not justified by the small chance of finding a potentially treatable abnormality. Or people simply decided they didn’t want the relatively large radiation dose (a whole-body CT exposes a person to ~15 mSv radiation, roughly a tenth of the exposure of Hiroshima survivors).

But the practice of whole-body CT scans lives on in the tiny corner of the market known as “executive physicals.”

In a recent paper in JAMA, Deborah Korenstein, Maha Mamoor, and Peter Bach used a combination of internet searching and phone calls to identify highly ranked hospitals offering executive physicals. Executive physicals at these prestigious institutions routinely offered:

• Electrocardiograms (USPSTF grade D or I for low-risk patients)

• Chest x-rays (not addressed at all by the USPSTF, but not generally paid for by any insurance company in asymptomatic patients)

• Pulmonary function testing (USPSTF grade D for asymptomatic patients), and

• You guessed it: whole-body CT scans.

Unnecessary testing has downsides

The unnecessary testing of anyone–let alone your most highly-paid employees–is a three-headed spear. First, the exams themselves are expensive: around $5,000 each. Second, much of the testing that is unsupported by evidence is likely a waste of money, as we’ve discussed in a previous post, especially since your highly paid professionals are likely to outlive your other employees based on their income alone. But maybe more important is the potential real harm done by unnecessary testing.

A well-known example of this comes from South Korea. That country’s national health insurance program initiated an aggressive cancer screening program in 1999 that screened for breast, cervical, colon, gastric, and liver cancers, mostly free of charge. With certain cancers this is a potentially good idea, even though cancer screening doesn’t seem to make people live longer as a whole. But patients in South Korea were frequently offered thyroid cancer screening with neck ultrasound as an optional add-on for a modest cash price.

By 2011, the rate of thyroid cancer diagnoses in South Korea had jumped 15-fold. This was not because of a new toxin in South Korean drinking water or because of radiation exposure. The entire increase was due to the new detection and diagnosis of “papillary” thyroid cancers that were too small and slow-growing to be felt on physical examination, but were easily detected with ultrasound testing. Because they were small and slow-growing the cancers were also unlikely to ever kill the patients in whom they were discovered.

So what was the downside? All the surgeries to remove cancerous thyroids had consequences (in addition to the surgery’s ~$5,000 cost). In addition to thousands of people who now needed to be on a daily thyroid hormone pill for life, South Korean patients experienced a huge increase in common complications of the surgery: two percent experienced permanent hoarseness due to paralysis of one of the vocal cords, and a whopping eleven percent now needed to take high-potency vitamin D and high-dose calcium multiple times a day for the rest of their lives to prevent muscle cramping because of damage to the calcium-controlling parathyroid glands that lie next to the thyroid.

This might be acceptable if a significant number of years were added to patients’ lives as a result of this. But that has not happened. A person in South Korea has the exact same (very small) chance of dying of thyroid cancer now as she did before this movement. That is to say, all this testing had only downside; there was no upside.

So the next time your company is negotiating the health benefits of its executives it might be worth asking what evidence supports any additional testing offered to C-suite folks. It may cost more than you think.

Health literacy is not just important for C-suite individuals.  Considering that only 12% of Americans having proficient health literacy, and that health-illiterate people spend 80% more on healthcare than their health-literate counterparts, it’s crucial to educate your employees!  The Kansas Business Group on Health offers discounts on resources to educate you employees on how to be better consumers of healthcare.

What’s the Value of an Annual “Checkup”?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

Are annual checkups all they’re cracked up to be?

Remember Cigna’s “Doctors of America” ads?

“We are the TV Doctors of America,” says McDreamy.

“And we’re partnering with Cigna to help save lives,” says Dr. John Carter.

“By getting you to a real doctor for a checkup,” chimes in Cuddy.

But to put our “Devil’s Advocates of America” hats on: what if this annual checkup business isn’t all it’s cracked up to be?

It is reasonable to hold any potential medical test or treatment to one of three standards:

1. It makes the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees, for starters. It could even apply to things like bone mineral density screening, sometimes referred to as “DXA,” which linked with osteoporosis treatment may make no difference in the risk of death, but clearly prevents hip, wrist, and spine fractures.

2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolong many lives).

3. Finally, if a treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money [disclaimer: the KBGH is closely linked to Health ICT through the Medical Society of Sedgwick County, which receives CDC funding to promote things like blood pressure control, cholesterol management, and diabetes prevention].

Many of the tests and treatments medicine offers do not live up to that rubric. This may be why the Cochrane Review, which many consider the highest level of evidence in medicine, published a review in 2018 stating that “Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.” So when the TV Doctors of America say you need an annual checkup, what they surely mean is not that you need an old-fashioned sit-down with your doctor where, at the end of the visit, she gives you a “clean bill of health.” No. What I hope they mean is that you need to have access to a primary care provider. Investigators in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51-day increase in life expectancy, which doesn’t sound like much, but is pretty big by medical standards. Some estimate that a doctor practicing at the top of his license adds about 4.5 net years to the average patient’s life. Not too shabby.

“Systematic offers of health checks are unlikely to be beneficial and may lead to unnecessary tests and treatments.”

What actually improves or extends someone’s life?

What the TV Doctors of America really mean is that you should have certain preventive services like immunizations and periodic screenings for health conditions that, if left untreated, can profoundly shorten your life. Most of these aren’t sexy. Probably the most effective preventive medical intervention, for example, is a simple periodic blood pressure check with medications if your blood pressure is too high. Sexier things like cancer screenings tend to have a “disease-specific” benefit, meaning they prevent you from dying of colon, prostate, cervical, breast, or lung cancers specifically, but they may not make people live longer as a whole.

If there is doubt in your company about what services you should be providing, a good place to start is with the United States Preventive Services Task Force (USPSTF), a rotating group of doctors that follows very specific rules to evaluate the risks and benefits of specific screening. Their opinion holds a lot of weight because any test given a “B” or better rating is mandated to be covered by your insurance. Examples of “A” rated services are things like tobacco use counseling and interventions, blood pressure screening in adults, and screening for cervical and colon cancers, which are all strategies that easily conform to our rubric. Cholesterol testing in people without diabetes or heart disease gets a “B.” Screening for prostate cancer in men aged 55-69 with a prostate specific antigen (PSA) test is a good example of a “C” rated service, since it has no overall mortality benefit and its disease-specific mortality benefit is largely offset by the harms that screening can cause (prostate biopsies and surgeries can cause bladder leakage and erectile dysfunction, among other things). PSA screening for prostate cancer in men aged 70 or older gets a “D” rating because it appears, in the hive mind of the USPSTF, to cause more harm than it prevents; that is, it violates rules #2 and 3.

What does this mean for employers?

How do you apply this to your workforce? Start by being an informed shopper for any workplace wellness services being offered to your company. Whenever a wellness provider tries to charge you a lot of money for offering annual “wellness checks” or “health risk assessments,” check their recommendations against the opinion of the USPSTF (or have us at KBGH check them for you). If the amount of testing they’re charging far exceeds what the experts recommend, ask them why.

Second, work on the health literacy of your employees (we can help with this). It’s hard as a patient to turn down testing or treatment your doctor offers if you don’t have the background to know what works and what doesn’t. I’m a doctor myself, and even I’ve felt vulnerable being squeezed through the gears of the medical-industrial complex.

Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

Links for August 17, 2018: bull riding is still a thing, Round-up for breakfast, and Thai food diplomacy

Eight seconds on a bull seems like forever. Forever. I'll now add bull riding to my list of sports in which you can smoke and still kick ass. The only other sport on the list is bowling, FYI. Curling is under consideration.

Round-Up is in all our food. All of it.

Well, at least all of it that's made of grain. I don't have conclusive evidence that this is a bad thing (The WHO International Agency for Research on Cancer said glyphosate was probably carcinogenic in 2015, but a subsequent WHO report said it was unlikely to be carcinogenic). But is sure as hell doesn't seem like a good thing. I always suspected I'd had my lifetime dose, having grown up on a farm, but we were total amateurs in the 90's compared to now:

USGS, https://on.doi.gov/2wb94bn

Thai restaurants are over-represented in America. It's not an accident.

"Using a tactic now known as gastrodiplomacy or culinary diplomacy, the government of Thailand has intentionally bolstered the presence of Thai cuisine outside of Thailand to increase its export and tourism revenues, as well as its prominence on the cultural and diplomatic stages. In 2001, the Thai government established the Global Thai Restaurant Company, Ltd., in an effort to establish at least 3,000 Thai restaurants worldwide. At the time, Thai deputy commerce minister Goanpot Asvinvichit told the Wall Street Journal that the government hoped the chain would be “like the McDonald’s of Thai food.” Apparently, the government had been training chefs at its culinary training facilities to send abroad for the previous decade, but this project formalized and enhanced these efforts significantly."

And the Thai government even has quality control:

"...Thai diplomats in the US have been charged with supporting Thai restaurants in both logistics and strategy. “When we received the award, the Ministry of Thai Trade actually came to my restaurant and we discussed about how we can promote more and how they will support us in getting more products from Thailand,” said John Sungkamee of Emporium Thai in LA. “She suggested I should look into promoting the Thai rice berry. She also recommended the suppliers to obtain them from.” Sungkamee told me that he and other Thai restaurant owners across the country maintain a group chat, and the now-former Thai Consul General in LA has been an active member."

I've had several Impossible Burgers. They're amazing

A few years ago I made a choice to eat very little meat. Everyone who comes to a this dietary decision gets there for one of several reasons. For some, it's a matter of animal welfare. For me, it was the impact of excessive meat intake on my personal health: meat, particularly red meat and processed meat like bacon, has been linked to increased risk of heart disease, cancer, and other diseases. Plus, beef in particular is astonishingly carbon-intensive; were people to forgo only red meat in favor of beans (while, mind you, continuing to eat pork and poultry), the U.S. would come very near Paris Accord carbon emissions goals, all without a change in driving habits or other energy production from fossil fuels, and without a change in efficiency. 

Giving up meat for me was astonishingly easy. I don't miss it. Were you to ask me to give up sweeteners, we'd have a problem. I like desserts more than I should, and despite my frequent screeds against bug juice, I have an occasional caffeine-free Diet Coke. But no meat? No problemo. Part of the reason for this is that we've had a big increase in the availability of meat substitutes in the past decade or so. This doesn't affect me so much as it affects people who eat with me. I can make meals that are almost meat that I can serve to carnivorous friends and family without feeling like I'm depriving them of anything. But hamburgers, the quintessential American food, have been a problem. I've tried multiple veggie patties and black bean patties. They're all mostly okay, but they're no substitute for real meat. You have to have in your mind that you're not eating a hamburger to enjoy them. You tell yourself, "This is a good veggie burger," but you can never convince yourself that you're eating a real-for-real hamburger.

Then I heard about Impossible Foods and their bleeding vegan hamburgers. I was intrigued, but there was no place near home for me to try one. But last summer I was in Houston a week or two before Hurricane Harvey. We found a Hopdoddy just west of Rice Stadium:

This was directly adjacent to Rice's semi-famous 1/3 mile "Bike Track," whose popularity I assume is at least partly due to the apocalyptic artillery-grade roughness of the surrounding streets. Hopdoddy was pushing the Impossible Burger hard:

But that didn't mean they didn't have the customary pile o' beef in their kitchen:

And it didn't mean that when I ordered on the waitress wouldn't say I was "brave." But when it arrived, so far, so good:

My burger looked like a million bucks. But I didn't get a chance to find out if my burger bled; it was well-done:

Impossible Burger has the look and feel of beef. It has the mouthfeel of beef. It just does. For all intents and purposes from the consumer end, this is beef. I tried a bite of my son's regular patty for a taste test. I'm a bit of an unreliable witness here; my enthusiasm for meatless foods taints my impression of these things. But honestly, the only difference was that his real burger was saltier. I suspect Impossible keeps the salt content lower to avoid dryness.

I liked the one I ate so much that I convinced my then-ten year-old daughter, a notorious carnivore, to try one. She will eat veggie patties, begrudgingly, the way somebody who's tasted whole milk will settle for almond milk on her cereal if they don't have a choice. But after tasting mine, she was enthusiastic to get her own. And she's had several since.

The primary ingredients are wheat, coconut oil, potatoes, and heme. Heme is part of the molecule that carries oxygen in your bloodstream: "hemoglobin." Impossible gets its heme in the form of soy "leghemoglobin." Their website says they chose it because of taste and lack of allergenicity. I suppose this means people won't get a rash if they eat it. Not that I knew hemoglobin allergies were a big problem.

If you're the anti-GMO type (I'm most certainly not), beware that Impossible's leghemoglobin is produced by a genetically modified yeast. But it is 100% vegan. It's not gluten-free, which is a bummer for the small fraction of the population with celiac disease. For the remaining 99% of us, it's neither here nor there. Impossible burger patties are kosher.  Halal are anticipated later this year.

My second Impossible Burger was in Washington, D.C., for a work trip. My daughter's, ironically, came with bacon:

My wife's medium-rare (not ordered that way, but delivered that way) patty gave us a chance to taste the heme without the searing. It definitely loses something. The seared heme is important: 

I tried to convince my daughter that the tater tots were also "Impossible," but that since they were naturally made of potatoes the impossible factor was figuring out how to make them out of animals. She didn't buy it: 

Impossible Burgers are now served in more than 1,500 restaurants. Since April, White Castle has been selling Impossible Sliders for just $1.99. After trying Impossible Burgers myself, I'm convinced that meat production in the way we've been practicing it for the past 100 years has an expiration date. We simply won't tolerate the health and environmental consequences of it when we have alternatives that are this good. I'm not here to tell you that Impossible Burgers represent any kind of achievement. Quite the contrary: as good as they are, they're just the beginning. Meatless "meat" is the worst today that it ever will be. It will only get better from here. Next phase vegetarian chicken? Faux eggs? Faux seafood? 

Links for Wednesday, August 23, 2017: metformin reframed as wonder drug, cane vs beet sugar, and medicine as an inefficient time suck

Does metformin "promise" to extend life?

It may promise a lot of things, but until I see RCT data, I'm not convinced that we should put an old anti-malarial drug in the water. Metformin, I mean. And that RCT would be the TAME Study. Observational studies of metformin and cancer have been promising, but...

In two controlled trials involving patients with advanced pancreatic cancer, a notoriously difficult cancer to treat, metformin failed to provide any benefit.

So I'll hold out ultimate judgement until after the TAME Study. But this smells a little like 20 years ago when pharma invented osteopenia to sell bisphosphonates, and then tried to encourage "prophylactic" treatment of even osteopenia. (metformin link via marginalrevolution.com)

Are our cooking efforts sabotaged by the substitution of beet sugar for cane sugar? 

Brown cane sugar -- a combination of sugar and molasses, both inherent in the sugarcane plant -- is produced naturally as part of the process of refining white cane sugar by the traditional method, crystallization.

Brown sugar from C & H Sugar Co. and other cane refiners uses the process, but beet sugar is different. It's made by refining the sugar all the way to the final white granular stage, stripping off all the molasses because beet molasses is unfit for human consumption (it's recycled as cattle feed). Then cane molasses is added back into the sugar through a process called "painting."

Painting coats the granules but does not necessarily penetrate them -- the molasses can sometimes be rubbed right off.

As with white sugar, these different types of sugars act differently in the kitchen.

The best medical analogy for this seems to be the auto-substitution of in-class medications by insurance formularies. Detemir substituted for glargine, for example. 

Is medicine a "low-impact" profession?

The folks at 80,000 hours think so, noting that the number of people whose lives will be extended by a single doctor is low, or "pretty modest," as they say:

This analysis confirms the contentions above: physician density is negatively correlated with burden of disease16; the social determinants of health explain more of the variance in health outcomes than physician density17; there are steeply diminishing returns between increases in physician density and decreases in burden of disease16. Further, the ‘bottom line’ figures (which are likely optimistic) suggest an additional doctor adds four health years for every year they work. This is a lot less than can be accomplished through even modest donations to effective charities, and so suggests the ‘direct impact’ of medicine is pretty modest.18

(link from slatestarcodex.com)

Links for Monday, August 14, 2017: Hippo meat, better air from more cycling (and fewer cars), Mark Twain cycling, and CRISPR pigs

America once seriously considered importing hippopotamuses as livestock. 

"The idea was to import hippopotamuses from Africa, set them in the swamplands along the Gulf Coast, and raise them for food. The idea was to turn America into a nation of hippo ranchers."

The fact that we don't have hippos living in the Mississippi River eating water hyacinths and being harvested for meat is no tragedy; introduced species have a rough history in America, as anyone in Hawaii can tell you. But as author John Mooallem notes, the fact that we no longer live in an America where kinda-sorta crazy ideas like this can be debated non-ironically is kind of sad. (link from longform.org)

Notice the 2016 link. But it sounds as though 2017 was no different. Link from globalcyclingnetwork.com

When London took cars off the road for Ride London, the air quality got better. As in, shockingly better. 

"Air pollution is believed to be a contributing factor in some 9,000 deaths in the UK capital alone annually.

According to a story published in The Times today £383,000 of taxpayers’ money has been spent by Government ministers on fighting efforts to clean up the UK’s air. Despite this, Britain recently announced plans to ban the sale of petrol and diesel cars by 2040 following a similar commitment in France."

Mark Twain's "taming the bicycle" is one of the best pieces of cycling writing ever.

This essay makes me so happy. It's a joyful, self-deprecating account of learning to ride a pennyfarthing, complete with copious use of Pond's Extract. But this essay makes me so sad. It's better than anything I'll ever write, and Mark Twain didn't even try to publish it. Sigh. Link from bikesnobnyc.blogspot.com.

Adorable piglets modified via CRISPR eventually may be organ donors for humans. Or delicious, non-carcinogenic bacon. One of those.

That's where my mind went when I read this. The immediate application for CRISPR technology in animals may be to reduce their production of greenhouse gases, or decrease their carcinogenicity. But for now, organ transplantation seems to be where it's at, for obvious reasons:

Doctors won’t have to do much persuasion, however, to get patients to accept organs from another species. “There is so much desperation among people on transplant lists, and 20 a day are dying as they wait,” said Dr. Adam Griesemer, a xenotransplantation researcher and transplant surgeon at Columbia University Medical Center. “This could be a path to a transplant for them. Colleagues keep asking me when we’re going to do it.”

Link from kottke.org

Links for July 27, 2017: lead levels and crime, CTE, happiness in bariatric surgery, and the Fda's cheese problem

Are high lead levels associated with high crime rates?

In a sample fraught with selection bias, 99.9% of autopsied NFL brains had chronic traumatic encephalopathy.

This bothers me less than I might have thought it would. NFL players are small in number, they have a job that they know is risky, and they're pretty well paid for the work. The fact that they have a now well-documented complication of their employment is only mildly interesting. Where this research needs to go now is into lower levels of play. If evidence begins to accumulate that college, high school, or younger players are at risk for CTE, then wholesale changes are going to be needed in football or the sport is in real danger. 

People with a BMI under 40 are happier and healthier after their surgeries.

I'm a big, big fan of bariatric surgery for people with morbid obesity. We simply have access to no other treatment that improves quality of life and prolongs life to the extent that surgery can. But now there's some evidence (albeit weak) that people should have surgery earlier, not later. In a study published in JAMA Surgery, investigators found that people who had surgery before their body mass index, or BMI, hit 40 were about 12 times as likely as people with higher BMIs to get to a non-obese BMI (that is, less than 30) after surgery. A couple things to consider here: first, surgeons want to operate, so we should acknowledge their bias in this study; of course they want people with lower BMIs to qualify for surgery. It opens up more patients for them and they get to operate on a less sick, less complicated population of patients. But second, weight isn't the only thing we worry about post-surgery, so why does this matter? Because people who got to a BMI of less than 30 were much more likely to be able to stop medications for cholesterol, diabetes (especially insulin), and blood pressure. They were also much more likely to see a remission in their sleep apnea. Finally, the people who got to a lower BMI were just happier, with a satisfaction rate of 92.8% vs 78.0% for folks who didn't get to a non-obese BMI. The study can be tossed into the growing pile of studies showing that gastric banding sucks. Patients who had any other surgery--sleeve gastrectomy, gastric bypass, or duodenal switch--were 8 times, 21 times, and 82 times more likely, respectively, to get to a BMI less than 30 compared with those who got gastric banding. And that doesn't even take into account the disturbingly high complication rate of gastric banding. Take-home points? If you're considering bariatric surgery, get it sooner rather than later, and don't get a gastric band. 

The USDA is all about cheese right now.

I have mixed feelings on this. On the one hand, it seems a little absurd that we so misallocate food subsidies that dairy farmers are literally pouring milk into holes in the ground:

Farmers poured out almost 50 million gallons of unsold milk last year—actually poured it out, into holes in the ground—according to U.S. Department of Agriculture data. In an August 2016 letter, the National Milk Producers Federation begged the USDA for a $150 million bailout.

On the other hand, given the growing evidence that excess meat intake is shortening American lives, diverting some of that desire for meat toward cheese, yogurt, and other dairy products isn't the worst thing in the world. 

Links for July 17, 2017: open streets, placebo diets, hair dyes and cancer risk, the sedgwick county CHIP, bad sleep and junk food, and the lengthening of your life with dietary choices

Open Streets ICT is coming. Are you ready?

Are diets just placebos?

Is your hair dye increasing your risk of breast cancer?

Hair products, conveniently, seem to never get the wrath that other "artificial" lifestyle products (artificial sweeteners, preservatives, herbicides) get. Does this study change that? I doubt it.

Have you seen the Sedgwick County CHIP?

That's Community Health Improvement Plan, which is even more delicious than what you were thinking of...

Sleeping poorly may make junk food seem a lot more appealing.

The data is still maturing on this topic, but it's starting to look pretty obvious that we should all sleep more, for reasons obvious and not-so-obvious. I can speak from experience. During my internship, one of the hospitals I covered had a cafeteria that was free--in unlimited quantities--to trainees. I fell into a nasty habit of 3 am cheesecake binges during my in-house nights on call. It was ugly...

This paper deserves to be mentioned much higher in the list, but I may have more to say about it later. So...for the one-thousanth time, we have evidence that dietary choices can prolong or shorten your life.

Using one of three diet indices, investigators publishing in the New England Journal of Medicine found that "[a] 20-percentile increase in diet scores (indicating an improved quality of diet) was significantly associated with a reduction in total mortality of 8 to 17%." For the sake of comparison, taking a statin medication for cholesterol in high-risk people is associated with about a fourteen percent reduction in mortality. And to stave off the angry emails, I know that the statin data comes from high-quality randomized trials, while the referenced dietary study is observational. But still. 

June 13, 2017 links to confirm my pre-existing biases: No insulin, no BG checks and the cancer risk of physical inactivity and diet

If you're a diabetic person NOT on insulin, you probably don't need to be checking your blood sugar at home.

I like this paper for a couple reasons: first, it confirms what I already thought, which makes it my (and everyone else's, whether they admit it or not) favorite kind of paper. Second, it's by my old boss at UNC-Chapel Hill, John Buse (seen in that picture rocking a Willie Nelson-esque beard). Finally, it's a very practical look at what glucose monitoring is. If you're on insulin and can change your dose meal-to-meal and day-to-day, it makes sense to monitor glucose levels for safety and efficacy reasons. If you're on fixed doses of non-insulin medications, the act of glucose checking becomes much less practical, and just as big a pain in the ass as it always is. My screed against SMBG in this case, though, is called into question by the study. The investigators measured "health-related quality of life" at 1 year, and it didn't differ between the groups. So the people poking themselves didn't feel much worse than those who got off the hook. But I'm sticking to my guns: when it comes to self-monitored blood glucose levels in type 2 diabetics NOT on insulin, the juice (that's your blood) literally isn't worth the squeeze.

Some folks say that diet, physical inactivity, and the resultant obesity could overtake smoking in terms of cancer risk.

I say "no shit."

Spring link 5-pack April 26, 2017

What are Americans dying of? Spoiler alert: obesity. Second spoiler alert: complications of diabetes.

Artificial sweeteners may be associated with stroke and dementia risk. I've mostly given up artificial sweeteners, but not because of this paper. I'm making a bit of a Pascal's wager on artificial sweeteners: they're surely not good for us, even though they may not be as bad as sugar itself. So I take steps to avoid them, just like I take steps to avoid sugar itself. The fact that this paper didn't show any risk associated with sugar-sweetened beverages makes me a little suspicious of its results. Maybe the editorialists' note that people sometimes switch to diet soft drinks after they are flagged as "high risk" by their doctors is right. They're on their way to a stroke one way or the other, and they just happen to have switched to a diet drink beforehand.

Garden City, Kansas voted to raise the legal age for the purchase of tobacco or e-cigarettes to 21 years. The decision "grew from a request made by a group of Garden City High School students earlier this year." Garden City is the fifteenth (!) city in Kansas to make such a decision.

Exercise may help cognition (that's the thinking part) in the elderly. Seemingly if you work moderately hard for at least 45 minutes. What is moderate? According the ACSM guideline they used, it is hard enough to use "40%-60% heart rate reserve." That means halfway between your normal resting heart rate and your maximum heart rate, which is usually calculated by subtracting your age from 220. So if your normal heart rate is 70 and you're 50 years old, you have a maximum heart rate of ~170, so using 50% of your heart rate reserve would mean getting your heart rate to ~120. Confused? Well, "moderate" intensity is also about a 5 or 6 out of 10 in perceived exertion. There. 

The FDA is warning (again) about bogus internet cancer treatments. A couple observations here: 1) I can't believe it's only 65 products. That must barely scratch the surface. 2) I don't know if the fact that so many of the products are co-marketed for cats and dogs is a good sign or a bad sign. 3) Even a casual observer must be astonished that we know so much about how to prevent cancer, and it's not complicated, and it's generally cheap or even money-positive (don't smoke, get a little exercise, eat fruits and vegetables, wear sunscreen)

But yet we as a society are so much more interested in giving our money to snake-oil salesmen for untested bunk.

Here's to the MAMILs (Middle-Aged Men In Lycra)

*MAMIL nomenclature unabashedly stolen from Code Switch:

Since I'm a MAMIL most days, at least for an hour or so, and since I know that even weekend warrior-style sporting activity is associated with a 34% reduction in the risk of dying, a 40% reduction in the risk of dying of a heart attack, and a 17% reduction in the risk of dying of cancer, I headed out to Benton, Kansas today for the final race in the Rage Against the Chainring series, the "Rage of Oz." This is the Land of Oz, after all, or the "Land of Ahs" if you prefer:

And, well, we've got us some rage:

*may or may not be from Kansas. But probably is. 

So there we were, slippin' and slidin' through the Flint Hills south of Benton, Kansas, for 50+ miles: 

It's not as flat as it looks. And for all you mathy-types, it was a two-lapper. 

The end result was 4th place in the "B" class (sort of like scoring in double digits in the JayVee basketball game), but also a Saturday morning that I'm proud of and a statistically lower risk of dying today or tomorrow.

And some very muddy legs:

You can get a Belgian suntan even on cloudy days. In fact, more Belgian suntans are acquired on cloudy days than sunny days.

Sausage Linkfest April 21, 2017

Like them or not, soda taxes seem to work. That is, they work to reduce sugar-sweetened beverage consumption. Time will tell if we can trace any health benefit back to them, like we did with trans fat bans. 

School shouldn't start before 8:30, say the sleep people.

Biking to work is associated with a 41% reduction in the risk of dying over five years. Biking was also associated with 45% lower rates of cancer and a 40% lower risk of dying of cancer. And, as has been noted here before, it's associated with having a shitload more money in your bank account.

Even short-term corticosteroid use is harmful, says a review in the BMJ, with accompanying coverage from the NYT. This is ironic, considering a very recent well-publicized study advocating for 10 mg of dexamethasone in place of antibiotics for sore throat. So a couple comments: first, even the "low-dose" steroids the BMJ article talks about constitute a potentially huge dose (20 mg daily). Second, 10 mg of dexamethasone is just a gigantic, chemotherapy-level dose. It is saved by the fact that dexamethasone has a half-life of only ~3 hours, so most of it is gone by the second day. But still...whatever happened to chicken soup and time for things to get better? *sigh* I guess dexamethasone isn't any worse than the cursed "Z-Pak" that urgent cares seem to hand out like Halloween candy.