How Much Health Should Flow Through Your Smartphone?

We at KBGH get pitched a lot of apps. Apps for blood pressure, apps for blood sugars, apps for lab and imaging pricing. Lots of apps. In the roughly two years that the current staff has been at KBGH, I think pitches from outside companies have covered most of medicine in apps, save a few small nooks and crannies. I don’t think we’ve been pitched a fertility app yet, for example, but I might be mistaken. And this isn’t an ivory tower problem for us; we’re in on the creation of apps as well. We’re working with WSU’s College of Innovation & Design on a Rural Health Challenge to, in part, help connect rural patients with their doctors via technology. That technology may include smartphone apps since, according to a Cochrane review, there is “low-certainty evidence of the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of [cardiovascular disease].”

But, as we’ve blogged about before, your computer or smartphone may not be the most direct route to a healthy, happy life. Excess time on devices, particularly that spent on social media, may be bad for us and may paradoxically exacerbate loneliness and isolation. So how much of our medical care should run through our phones? I’m generally optimistic about the future of telemedicine, but I’m pessimistic about the attention economy, in which companies are incentivized to grab increasingly big chunks of our time.

Regardless of my opinion, though, people have thought hard about what should go into a good medical application. Here are four elements paraphrased from Swiss investigators Kenny R. Lienhard and Christine Legne:

1. Mobile medical apps should guide a patient through every step of instruction, setup, clinical measurement, and analysis and feedback. Imagine that you just downloaded an app to your smartphone to help communicate blood pressures to your doctor. The app shouldn’t just tell you how to send the blood pressure. It should give you instructions on the technique for where to place the cuff. It should provide feedback if it senses your technique is wrong, like if different readings get very different results. It should help you analyze the numbers; if your blood pressure is consistently high or low, it should prompt you to talk to your doctor about it.

2. The user interface should be adapted to cope with patients’ physical and cognitive restrictions. This goes without saying. The American Medical Association (AMA) recommends that health care materials be written at or below a sixth-grade reading level. But the interface should also account for people with impaired vision or hearing or differences in dexterity, to name a few.

3. A mobile medical app should build on a robust medical knowledge base, ensuring an evidence-based approach to mobile app design. This one is tougher because most of us–present company included–don’t necessarily know the ins and outs of app design. But manufacturers can search out the best medical advice for many circumstances and account for those in the testing of the app.

4. Mobile medical apps should facilitate both patients’ and physicians’ routines. This is crucial, and it applies directly to work we’ve done at KBGH. It is great to get blood pressure results to your doctor. But it’s even better if the app, upon seeing those blood pressure results, can make a treatment recommendation to your doctor. We call this “decision support.” The app may give bad advice once in a while, like recommending a thiazide diuretic for a gout patient, but making more sophisticated decisions is what the doctor is there for.

What experiences have you had with medical apps? Let us know!

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.

How to break up with your phone, Double Arrow Metabolism edition: Days Six and Seven

Saturday's (Come back to [real] life) assignment: Get back in touch with what makes me happy in my offscreen life. I'm asked to complete an exercise:

• I've always loved to...ride my bike
• I've always wanted to...publish something non-academic
• When I was a kid, I was fascinated by...reptiles
• If I had more time, I would like to...write more
• Some activities that I know put me into flow are...none. Ever. Don't get me started.
• People I would like to spend more time with include...friends from college

I'm supposed to make a list of specific fun, off-phone things to do in the next few days. Here goes:

1. Visit the Monet to Matisse exhibit at the Wichita Art Museum
2. Volunteer for Bike Walk Wichita
3. Meal plan for the week
4. Ride my bike every day
5. Visit the herpetarium at the Sedgwick County Zoo

Sunday's (Get physical) assignment: Make some time to get back in touch with your body by doing something physical and enjoyable. I plan to commute by bike to my volunteer activity with Bike Walk Wichita today. Two birds, one stone.

The second assignment is to buy an alarm clock so as to more effectively banish my smartphone from my bedroom. I've been thinking about doing this for a while. My trusty, rusty old clock radio from college has been commandeered by my daughter, so now when I wake up in the night I can't tell what time it is without looking at my phone. My beloved George Nelson clock is hard enough to read during the day:

I'm not super-pumped about the style of the normally reliable Wirecutter's top pick, so I'll add "shop in-person for a clock radio" to my list of non-phone activities for the weekend. 

Links for Friday, December 29, 2017: food swamps, happiness from QI, and the persistence of ineffective treatments

So long, food deserts. Helloooo, food swamps

...food swamps had about four unhealthy options for each healthy one. Food swamps were a strong predictor of obesity rates—even stronger than food deserts were. The relationship between food swamps and obesity was especially strong in areas where people lacked both their own cars and access to public transportation.

See primary paper here.

Bob Badgett has thoughts on happiness and quality improvement

The Dunning-Kruger effect (which applies to docs) is the phenomenon in which difficulty in recognizing one's own incompetence leads to Inflated self-assessment. That is, the worse you are at your job, to some extent, the higher you rate your ability to do that job. Uplifting stuff when we think about management. 

Why do doctors keep recommending treatments that don’t work?

Tough question that Eric Patashnik does a good job of summarizing in a manageable length. We're all victims of our own status quo bias:

In the US, even modest reforms to use taxpayer money to fund research to learn what treatments work best, for which patients, have engendered controversy. Republicans famously charged that the establishment of the Patient-Centered Outcomes Research Institute (PCORI) through the Affordable Care Act, would lead to the creation of “death panels.” The politicians made that argument even though the agency only funds studies and was given no authority to make policy decisions or payment recommendations. PCORI has yet to have a significant impact on clinical practice. It faces a sunset date of 2019, and its future remains unclear.

"The greatest favor you can do is...put away your phone."

Sherry Turkle from the MIT Media Lab talks about the frequency she hears people say they'd "rather text than talk." People say they feel less vulnerable when they text than they feel in a face-to-face conversation. I agree. I feel less vulnerable texting, too. 

So don't be a phone worm. When I was in medical school in the late '90s, I remember classmates making fun of a woman in our class who was pathologically attached to her cell phone. We'd all just learned the word "pathologic," and our family members were already asking us for medical advice, so we all felt comfortable making the diagnosis. Anyway, hers was the phone that would ring its Nokia ringtone multiple times a day to interrupt class back when this was still a novel occurrence:

In the year 2017, I'm not sure she'd even hit the average cell phone use. Recently, at my kids' gymnastics lesson, I was flanked by two women on cell phones. The first one sat to my right, bouncing off my shoulder as she sat. I forgave her for this, because she couldn't see me past the smartphone glued to her left ear. Then she proceeded to scream intermittently at two kids who were not in the gymnastics class, all while never removing the phone from her ear. I didn't blame the kids for being wound up; it was after school, and they were stuck in a building watching a sister when they would've undoubtedly preferred to be outside on the playground. But she couldn't be bothered to interrupt what seemed like a very non-urgent conversation.

I moved to a quieter place, sacrificing my chair for the floor. Then, three feet away, a second person started talking at full voice on her cell phone, telling the unfortunate listener on the other end repeatedly how pissed she'd been earlier in the day. Keep in mind, it was sunny and 66 degrees outside. Either person stepping outside to take her call would have been healthful and humane. But both women, insofar as my amateur observational skills could tell, sat in the middle of a crowded room and talked on their phones for the duration of the one-hour practice, save for the intermittent screaming at their kids. One child actually begged lady number two not to talk on the phone anymore, and was told to "zip it." A third man, who I assume was also a parent, broke his phone conversation only to tell a toddler to "stop fucking around." The toddler did not heed his instruction, and the man was soon sufficiently lost in his talking and texting to allow, shall we say, ample f'ing around, toddler-style. 

Sherry Turkle doesn't get into this directly in the brief video above, but this is all consistent with her observations that technology is killing social skills. We collectively show decreased empathy and a decreased ability for self-reflection. A big part of my job is handling sometimes delicate negotiations within clinics or within medical systems or between payers and doctors. In those situations, vulnerability is key. If the interested parties can't look one another in the eye and feel insecure and feel like their decisions impact the other people around the table, we get nowhere. 

Don't get me wrong. I've taken my share of calls and texts in crowds. But I've felt like an asshole almost every time. So to keep from being a hypocrite, I've set my phone to no alerts for messages or emails, and I frequently put it on sleep mode, meaning it won't ring unless an immediate family member or neighbor calls (I figure the neighbors have the best view of my house burning down). And though I've occasionally feared that this would kill my productivity, I'm fairly certain now that it does the opposite. I'm more productive the more time I spend apart from my device. People think email is urgent, for example. According to psychologist Dan Ariely, it's not. Yuval Noah Harari, author of some incredible work including Sapiens, meditates for two hours a day. And the astonishingly productive computer scientist and self-help writer Cal Newport is "indifferent" to his smartphone, still subscribes to paper newspapers, and only upgraded from a flip phone because his wife guilted him into it when they had their first baby. 

So here's a challenge for this week: Go outside your phone (comfort) zone. The next time you're standing in line waiting for something to happen, or watching your kids jump on the trampoline, or between innings at a softball game, or waiting for a movie to start, leave your phone in your pocket. Better yet, take it to whatever vehicle brought you to the game (except your skateboard; skateboards are a bad place to store a phone). It'll be hard to do, but you have the strength. Concentrate on your breathing. Once you've safely stowed the phone away, look at the others around you. You might have to work for some eye contact, because they probably aren't following the same rules you are. While you're gyrating around trying to get them to look at you, think about their stories. It'll give you something to ask them about. If they won't talk to you, make like Yuval Harari and make this time your meditation. If you're not the meditative sort, think about what you want to accomplish with the rest of the day. Make a mental plan. For a few minutes, don't be a phone drone.

See also: CRANK UP THE BASS, HOW ELSE CAN YOU CRANK UP THE BASS?, SOCIAL MEDIA IS A SET OF COMMON PLATFORMS TO DRAW OUT OUR WORST TENDENCIES, HAVE SMARTPHONES DESTROYED A GENERATION? 

Links for August 30, 2017: self-propelled cyclists, what makes life worth living, and Google's depression test

In the Vuelta a Espana, riders frequently have to ride back over giant hills to get to their team buses from the finish line.  

What makes life worth living? 

These astounding things, which you will soon encounter and see for yourself, are so easy to lose sight of, and there are almost as many ways of doing that as there are people. That is why I am writing this book for you. I want to show you the world, as it is, all around us, all the time. Only by doing so will I myself be able to glimpse it. 

Google made a depression test  

More accurately, Google linked the Patient Health Questionnaire 9 (PHQ9) to search queries related to depression, the same way a calculator might pop up when you search "tsp to tbsp." 

Links for Wednesday, August 2, 2017: death of the high-top, marijuana makes you stupid, and spending money only makes you so happy

Are high-top basketball sneakers on their way out?

True story: I bought 3/4 top sneakers for my senior year of basketball over the objections of my high-school coach, who wanted everyone in true high-tops. I stepped on another guy's foot on the first day of practice and broke my fibula. He took this as evidence I'd erred in my shoe choice. The evidence says otherwise:

"There's no science out there, that we have at least, that proves that a high-top shoe is more effective at reducing ankle injuries than anything else," says Kevin Dodson, Nike's senior design director for basketball footwear. 

Marijuana probably makes people do poorly in school, and it's not because they study less

So, with decriminalization and legalization of marijuana occurring nationwide, let's put the drug where it belongs: right beside tobacco and alcohol, two substances that, while not sinister enough to be made illegal, are clearly not good for you and should be mostly avoided.

Is the old adage to "Buy experiences, not things," wrong?

[this] helps us see the car-buyer’s true problem: not that he’s prioritising objects over experience, but that he’s pursuing the wrong kind of experience. He wants to receive a predictable, consistent daily dose of pleasure from owning a car. But that’s not how pleasure works: if the holidaymaker ends up happier, it’ll be because she got to enjoy anticipating the trip, experiencing it, then consigning it to memory, where it can be burnished until it’s perfect (or, if it went terribly, turned into an anecdote that’s even more fun). If our shallow materialist were to use his vehicle to pursue unpredictable, sociable and one-off experiences – like, say, a road trip with friends – he’d stand just as much chance of happiness.

So these new studies seem to indicate that it's not a simple matter of whether you buy things or experiences; it's a matter of what purpose the things you buy serve. If you buy a Faberge' egg (to use the example in the article) to simply put on a shelf in your office to be dusted, it's unlikely to make you any happier. If you buy that same egg to use in a game where it's passed around to close friends and family who are obligated to write a story about it and distribute it at Christmas, it may cause many people to be much happier. 

Go to church, you heathens, and adopt a perspective of abundance

I can remember one time in my life that I've asked God for help. I'm not proud of that fact. There were surely other times that I can't remember right now. I think my privileged life has something to do with it; I just haven't had that many chances to suffer.

It was in my senior year of cross country. I was running my hometown meet. 

Bowl cuts forever.

High school cross country races are a relatively anonymous affair. They don't draw big crowds, because people don't want to drive two hours to watch a twenty-minute race. So being at home was a big deal. I wanted to give the home crowd what it wanted, I guess, so I foolishly tried to keep pace with a kid from Liberal who was much, much faster than me. The race was 5k (3.1 miles), and at about 2.5k I knew I was in trouble. I figured I could limp home and still finish in the top ten (and I think I did, but I can't prove it). But to do so would mean going to a very dark place. I made promises to God that day, and I ran one of my fastest times: 16:59; not world-class, I know, but fast for me. If God had anything to do with it, I haven't remotely repaid the favor.

But I digress. This post isn't about my religion, or lack thereof. I attend church, but I'm not what any religious person would call a believer. Some of it boils down to the fact that I'm a bit of a skeptic in general and even more of a hermit. I'm simply more comfortable being alone than being in crowds. But being alone isn't good for me. So off to church I go most Sundays, wife and kids leading the way. And I frequently get something out of it, in spite of my smoldering skepticism. Take a couple Sundays ago, toward the start of Lent: our pastor brought up Nicodemus, the Pharisee who visits Jesus one night and serves up a big steaming pile of skepticism:

Nicodemus, in John 3:1-3:15, gets to play Scottie Pippen to Jesus's Michael Jordan.

Later on he reminds the rest of the Sanhedrin that the law mandates that a person be heard before he's judged, and later he helps embalm Jesus's body. And even later on, a group of newly-freed slaves founded a badass frontier town in his name in northwest Kansas. (which they only managed to hang onto with the help of some Osage, but that's another story)

Nicodemus deserves some credit here for asking Jesus questions about his radical philosophy. And the answer Jesus gives boils down to this: See your world through the lens of abundance, not scarcity. I think this philosophy applies to all of us. We're genetically programmed to cram high-fat, high-salt, high-sugar food into our mouths and lie on the couch because we evolved in an environment where calories were hard to come by, and where it took a helluvalotta work to extract them. But we also developed brains capable of rational thought, and now here we sit in an environment of caloric abundance, not scarcity. What we're programmed to seek now destroys us. It's as if we need water to survive, but we're being pulled into the center of a sucking whirlpool, being submerged in water that in excess quantity has become toxic. We're drowning. 

Through a lens of scarcity, we are compelled to hoard calories and stuff them in our bodies as quickly as we can. And we're similarly compelled to preserve those calories by kicking back in a La-Z-Boy. But our evolved brains tell us that we don't need to do this. Through a lens of abundance, the path toward happiness doesn't pass through a cheeseburger. 

Roadblock.

Instead, the path gently curves around that cheeseburger through something more sensible. Ultimately, you're happier if you skip the cheeseburger and eat something you won't regret later. This isn't a matter of deprivation. This is a matter of titrating our cheeseburger intake, just like we adjust our amount of driving or spending or physical activity, to achieve the maximum amount of happiness. 

From a perspective of scarcity, your neighbor's new car induces a twinge of jealousy. But from a perspective of abundance, you can see the year's salary you saved by driving your perfectly good ten year-old car as a reward for the regular 30-minute walks or 10-minute bike rides to the grocery store. A perspective of abundance sees these walks not as a chore, but as a choice. Or better, an opportunity. And if that opportunity coincides with, as writer Florence Williams calls it, a reversal in your "slow telomeric death march" (I'm paraphrasing), all the better. 

So back to church. Economist Jonathan Gruber from MIT has written about the effect of religion on well-being, and his thoughts were recollected in J.D. Vance's Hillbilly Elegy. Not only are people who go to church healthier and happier, but the effect seems to be causative. That is, church attendance seems to have caused people to be healthier and happier, not just that healthier and happier people tend to go to church more. To a skeptic, or to an *ahem*, coastal elite, there is a reasonable assumption that this personal benefit comes at a societal cost, since people who go to church are less tolerant than people who don't. And when it comes to some specifics like gay marriage, that's true. But for many other things, like immigration, religious people are much more likely to be tolerant if they're a regular church goer than if they identify as religious but stay home on Sundays. 

As Easter dawns, I'm sitting in western Kansas wondering what it is about the morning ritual of church that makes people healthier. My religious half says that recognition of a higher power comes with benefits: I scratch God's back, he scratches mine. But my scientific half says that it's not the religion that's doing the trick. It's probably the community that matters. The act of putting the needs of a group of people before your own surely causes some reapportionment of the mixture of good and evil humors that make up our sense of well-being. So if church or temple or mosque isn't your thing, join the PTA. Or volunteer at a soup kitchen a couple times a month. Or help with your community's health assessment. Do pedestrian/bike counts on the public paths when they're looking for volunteers. Volunteer at Boy Scout camp. Whatever your church becomes, do the duties it requires from a perspective of abundance. 

You might live longer. You might be happier.

Happy Easter!

Things you can control right now

There are a lot of things you can't control: the weather, the stock market, your neighbor's loud music. But many, many things are under your control, as pointed out by Lori Deschene. And how well you do at seizing control makes a huge difference in your health and happiness:

Right now, you can control:

1. How many times you smile today.

7. When you pull out your wallet for luxuries.

11. How often you notice and appreciate small acts of kindness.

17. The type of food you eat.

21. How much exercise you get.

22. How many times you swear in traffic. [I'd amend this to say that you can control how often you're in traffic at all. If you're swearing at traffic, chances are you are the traffic.]

27. The attention you give to your loved ones when you see them.

28. How much you enjoy the things you have right now.

41. Whether you formulate a new plan or act on your existing one. [this is my favorite]

44. Whether you smoke or drink. [unless you’re an alcoholic, in which case you are in control of whether or not you seek help from a qualified practitioner]

50. How much rest you get at night.

Freedom from the vortex

Maybe you’re sick. Not throwing up or coughing up blood or having a fever, at least not most of the time, but you’re on a few medications, probably for diabetes or blood pressure issues or cholesterol, and your doctor picks on you to change your diet or be more active whenever you see her. Your medications cost a couple hundred dollars per month, and every second or third time you visit the doctor she adds another one, or replaces an old, cheap medication with a newer, more expensive one.

And maybe you weigh a few pounds (or many pounds) more than you want to. You’ve tried a few diets, mostly Atkins-type stuff, or low-fat, or calorie counting, and you’ve lost weight a few times, but each time the weight eventually came back.

Maybe you’re tired all the time. You feel bad when you get up in the morning, you are fatigued and achy all day, and you don’t sleep well at night. Your doctor thinks you might be depressed, and you’ve tried a couple medications for it, but they don’t seem to help.

And maybe you worry about money. You spend a lot of it on medications, and you go through the drive-through a few times a month even though you promise yourself that you won’t, and you end up working longer hours than you want to because you need to make sure the bills get paid.

Maybe you worry about the environment. You worry that our habits are putting your kids’ futures at risk, and you worry about it, but you aren’t sure what to do. A couple of times you’ve clicked the button to buy carbon offsets when you flew somewhere, but mostly you just try to ignore the problem.

And maybe it hasn’t occurred to you that these are all different manifestations of the same problem. You read that right. There is a very good chance that your diabetes is just another manifestation of the same set of problems as your weight and your fatigue and your money issues and even climate change.

We’re gonna talk about how. This blog is about your health, but not in the way that you’re used to talking about it with your doctor. It's not about the “blood pressure, blood sugar, cholesterol,” kind of health that makes you feel like a gadget someone is tinkering with. It’s more about the “What do I look forward to when I get out of bed in the morning?” kind of health. Or the “What can I do today to make sure I’m happier tomorrow than I was yesterday?” kind of health. Health as freedom: freedom from false choices, freedom from medications (not all of them, but some of them), freedom from the, *ahem*, Bravo Sierra that passes for medical advice from celebrities and celebrity doctors. I’m talking to you, Dr. Oz.

You’re not going to see click-baity posts on this blog about some new supplement or cellulite-destroying cream. You’re going to see posts on how you can take control of your life back. I’m not talking about a life jacket to protect you from the evil, swirling vortex of drug companies, subsidized faux-food, and carbon-spewing cars and factories. I’m talking about the freedom of learning how to swim your way out of that vortex altogether, put your feet on dry land, and walk away. All those people wrapped in spandex and padding away on a commercial gym’s treadmill under creepy fluorescent lights: do you think they’re free? They sure don’t look like it to me. You, with dry feet, having sprung once and for all from the vortex and now walking one foot in front of the other toward a happier, healthier life: that’s what freedom looks like.

I intend to be your guide along this path to medical freedom. I want to teach you a new way to think about your health; a way that allows you to make decisions that are your own and that will get you out of the vortex. You know the last time you had a bad cold, and you felt guilty for taking all the healthy days you had before that for granted, and you wondered when you would finally feel normal again? Remember how you said to yourself that you’d never take a healthy day for granted again? Once you claw your way out of the vortex, you won’t. And it will be because you MADE that next healthy day. You will have made it yourself, with your own hands and feet and decisions. If you believe me, I’ll see you at the next post.