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.

No, your doctor doesn't know what that medication will cost you, either

In seven years of working on CDC grants focusing on improved care of metabolic diseases like diabetes and high cholesterol, I’ve come to think that two broad factors determine the success or failure of chronic disease management. First, doctors must overcome clinical inertia, the phenomenon in which the doctor and the patient follow the easier path in the encounter and generally leave things as they are rather than stop, start, or adjust therapy when indicated. As many as 85% of visits for high blood pressure are affected by clinical inertia, meaning that medications are not adjusted when the patient’s blood pressure, symptoms, or labs indicate that they should be.

Second, patients who are prescribed therapy must adhere to it. Only about a third of patients two years removed from a diagnosis of heart disease are still taking their cholesterol medications, for example, and only about two-thirds of patients with hypertension take their blood pressure medications on any given day.

One of the most significant predictors of medication adherence is cost. High-deductible plans, the old Medicare “donut hole,” high copays, and expensive branded medications have all been linked to lower adherence rates. One potential solution to this problem is good coaching by the physician and better choice of drugs at the bedside, driven by the physician’s intimate knowledge of medication costs. But do doctors really have a grasp on medication costs? A recent study (paywall) suggests, to no one’s surprise, that they do not.

Investigators sent a survey to 900 outpatient physicians (300 each of primary care, gastroenterology, and rheumatology). A mix of 374 responded. The survey contained a hypothetical vignette in which a patient was prescribed a new drug that cost $1000/month without insurance. A summary of the fictional patient’s private insurance information was provided, including her deductible, coinsurance rate, copay, and out-of-pocket maximum. Doctors were asked to estimate the drug’s out-of-pocket cost at four time points in a theoretical year as the patient’s cost-sharing changed due to other medical expenses.

Overall, 52% of physicians could accurately estimate costs before her deductible was met, 62% accurately used coinsurance information, 61% accurately used copay information, and 57% accurately estimated costs once she met her out-of-pocket maximum. (This performance actually exceeded my expectations. Prior to my exit from daily clinical medicine and entree into the benefits game, I think I would have failed most of these tests.) But only 21% of respondents answered all four questions correctly. The docs’ ability to estimate out-of-pocket costs was not associated with their specialty, attitudes toward cost conversations, or other clinic characteristics.

We need to acknowledge that this is a feature of the system, not a bug. Doctors are not trained to be HR professionals. They’re forced into the role. To quote Malcolm Gladwell:

I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we've made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.

Many people in the health care industry want the system to stay complex and opaque. That’s why large groups like the AMA and AHA are fighting some of the rules that have come about in the past couple of years. But I hope that your instincts match mine. We have myriad reasons to simplify insurance coverage, but I’ll start with two:

First, by reducing cost and administrative burden, we can make patients more likely to adhere to helpful therapy.

Second, if we can make the system more efficient by eliminating administrative complexity, we can leave doctors, nurses, pharmacists, allied health professionals, mental health professionals, dieticians, and others the brain power to do the work they were trained to do.

We hope you have a happy holiday season!

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.

Doctors, like orange juice, are better with breakfast

When I was a medical student, I thought I wanted to be a radiologist. I love the science. I like the physics of radiation, and my ego was invested in the idea of being a “doctor’s doctor” that other doctors looked to for wisdom and interpretation of diagnostic testing. Radiology checked all those boxes without the ooey-gooey autopsies and whatnot that are part of the daily routine of pathologists.

Then I did a radiology rotation.

I truly did like the science of x-rays and the conversations with other doctors and all the rest. I discovered one problem, though: I could not stay alert for hours at a time in a dark room looking at films. Come two or three o’clock in the afternoon, I would inevitably start to fade. Once, I even nodded off in the radiology suite. So, with the safety of future patients in mind, I decided to go a decidedly more well-lit and upright route, eventually completing a residency in internal medicine and a fellowship in endocrinology, diabetes, and metabolism. If nothing else, the work in endocrinology was ambulatory. If I’m moving, I can’t fall asleep.

I review my personal history as a wind-up for a research paper in JAMA Health Policy this last week (paywall). Investigators looked at records from primary care practices–these studies always pick on primary care docs–to see how likely a patient was to receive a “statin” medication depending on the time of day of his or her appointment. This is no casual question. Viral pandemics aside, cardiovascular disease remains the leading cause of death in the United States. Appropriate use of statin medications like atorvastatin (Lipitor), rosuvastatin (Crestor), and others dramatically reduce the risk of death from any cause in people at risk for heart disease.

Using United States Preventive Services Task Force (USPSTF) guidelines, which state that we should offer statins to anyone with known vascular disease, anyone with a diagnosis of a genetic problem called “familial hypercholesterolemia,” or anyone with a low-density lipoprotein (LDL) cholesterol level of 190 mg/dL or more (among other diseases like diabetes), the researchers found a disturbing trend. Compared with 8 am appointments, which the investigators used as their reference group, the likelihood of getting a statin was lower at all hours except 9 am. And the likelihood of getting a statin pretty consistently fell as the day went on: 88% at 9 am, 63% at 12 pm, and 69% at 3 pm. Overall, you were only 69% as likely to get an appropriate statin prescription in an afternoon appointment as you were in a morning appointment. Here’s the raw, “unadjusted” data:

JAMA Health Policy

And yes, radiologists make more mistakes later in their shifts, too. But this phenomenon is not limited to doctors. Judges sentence defendants more harshly just before lunch, when they’re hungry, and sentence more leniently after a break. Car crashes peak between 5 and 7 pm. Students taking standardized tests perform better earlier in the day and recover performance after rest. If you’re like me, you may have found that you do your best creative work earlier in the day, and you’re better off going to meetings or working on a task list later in the day.

The wellness industry has long coached patients to get the earliest available appointment of the day, but our reasoning has had more to do with the fact that if you go earlier in the day, you’re less likely to have to wait. With this data, we have to consider not only the time in the waiting room but the outcome of the visit.

[Disclaimer: the Kansas Business Group on Health has CDC funding to encourage appropriate use of statin medications.]

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 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.

We Need to Support Black Doctors

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 is a reprint of a blog post from KBGH:

The stark differences in health outcomes

We should never reduce any population of people to a set of statistics. Every one of those “statistics” has a story. But here are a few numbers that should get our attention:

African-Americans have a rate of COVID-19 that is three times higher than the infection rate of the population as a whole. Even worse, the risk of death of an African-American person with COVID-19 far exceeds that of other racial groups. While people of white, Latinx, and Asian descent have death rates that all fall between 20 and 23 deaths per 100,000 people, African-Americans have suffered a death rate more than twice as high: 50.3 deaths per 100,000 people. About one out of every 2,000 black people in America have already died of COVID-19. Let me repeat that: one two-thousandth of African Americans are already dead. From one disease. A similar death rate among white people would have resulted in almost 100,000 deaths just in that ethnic group so far. And sadly, Kansas has the highest racial disparity of any of the 41 states reporting such data.

But the damage is not limited to viral illnesses. Americans in general have lives about three years shorter than citizens of peer countries like those in Western Europe.

African-American men have a life expectancy that is, in turn, almost five years shorter than the American average. This means that an African-American man loses the better part of a decade in life expectancy compared to an average western European citizen.

And almost all of this difference is due to heart disease deaths, the risk of which is readily modifiable with solid, basic medical care.

What are the reasons for this disparity?

The basic medical care of black people is neglected for multiple reasons in our country, including a well-deserved historic lack of trust in the medical system by black people. Remember that in the Tuskegee Syphilis Experiment the U.S. Public Health Service intentionally and secretly withheld treatment from a group of black men with syphilis from 1932 to 1972 to study the “natural history” of the disease, jeopardizing the health of the men and any future partners. 1972!

A second problem is a dearth of black physicians, starting in training. African-Americans are tragically underrepresented in medical school. While African-Americans make up 13.4% of the American population, they make up only 7.3% of medical students. This disparity, while slowly shrinking over time, has real consequences. Patients may do better when cared for by someone who looks like they do. A 2018 randomized trial found that black men had far better outcomes when cared for by black doctors: rates of screening for hypertension, diabetes, high cholesterol, and obesity went up markedly in men with black doctors, by more than 25% in some cases. The difference appeared to be due to improved communication. Patients were simply more likely to bring up other health problems when assigned to a black doctor. Interestingly, uptake of “invasive” screenings—tests involving probing or a blood draw–increased only for the group assigned a black doctor. This would seem to reinforce the idea that trust, long missing with the medical establishment, is a vital part of the doctor-patient relationship. And the cultural knowledge imparted by someone from your own community can be priceless, something we have found in our CDC work on community health workers.

The increased rate of screening demonstrated in this study could have huge health implications. The investigators tried to estimate the effect of having more black doctors in the population as a whole and found that even a modest increase could reduce the black-white gap in heart disease mortality by 19%, and the and the overall black-white gap in male life expectancy by 8%.

Efforts are being made to attack this problem from the start. After all, the lack of black trainees isn’t simply the result of fewer black kids wanting to be doctors. Quite the contrary. Locally, the Medical Society of Sedgwick County sends member physicians every year to talk to high school students about the process of applying for and completing medical training. Nationally, the American Medical Association has a program called “Doctors Back to School” to facilitate physicians of color visiting grade schools to encourage minority students to consider careers in medicine. Kids cannot be what they cannot see, as the platitude goes.

But the real impediment to getting more black doctors probably lies in greater systemic reform of the type that is being aggressively advocated for nationwide. We need to see this as a failure of the system, not a failure of individual people. As you watch protests unfold nationally and locally, I hope your view of them changes when you see them through this lens.

Here’s to those who say “no”

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 is a reprint of a blog post from KBGH:

Comparing two patient visits

Every visit to a health practitioner is a story. Here’s the skeleton of how the story sometimes goes:

1. A patient makes a request for a specific test or treatment, often based on what he’s seen in advertisements or media. Take, for example, the time a perfectly ambulatory patient of mine saw a late-night TV ad for mobility scooters and asked me to prescribe one, since “Medicare [would] pay for it,” and since the patient found walking to be “exhausting.” 

2. The request is denied, hopefully for medically/economically sound reasons and not out of some peculiarity of the practitioner-patient relationship. What I mean here is that sometimes patients and doctors simply aren’t a good fit, and sometimes, strained relationship dynamics spill into decision-making. “Good” doctors allow this to happen less often than “bad” doctors, but I suspect no one ever quite gets to zero. I’ll leave the judgement of my “goodness” or “badness” to others. But in the case of my patient, with whom I had a very poor relationship (to my eye, largely because of near-constant requests like his request for the scooter), even though I had a good medical reason to deny the request (walking is good for you even if it makes you tired), my writing something to the effect of “over my dead body” in the chart probably betrayed my feelings.

3. The patient gives feedback of some kind. The relationship between patient requests and the doctor’s willingness to fulfill them has real, dollars-and-cents ramifications in that reimbursement is now sometimes tied to “patient satisfaction.” A study in JAMA Internal Medicine (paywall) found that about two-thirds(!) of visits involve a request for a specific test or treatment from the patient, and that 85%(!) of those requests are granted. But when requests are denied, patients report dramatically lower satisfaction. The effect is predictably strongest with requests for pain prescriptions or lab tests. The effect is almost nonexistent for stuff like antibiotics or x-rays. But back to our patient: maybe he complains to the office manager. Maybe he goes home and writes a scathing review on one of various doctor rating sites. (Advice to other medical professionals: don’t look these up. They hurt.) Patient Scooter chose to express his dissatisfaction not in writing, but by leaving a bowel movement on the floor in the elevator of the building. (I’m not making this up.)

4. Doctor uses that feedback to change his or her future performance/behavior. Or maybe he doesn’t, if the feedback is in the form of actual human excrement. (I did record the approximate size and quality of the stool in his chart.)

That story is not fair. It prioritizes the point of view of the medical professional. Here’s an alternate story, taken from a ProPublica piece a couple years ago:

1. A patient presents with a seemingly minor, but worrisome, finding: slight chest pressure that worsens when he exerts himself but gets better when he rests.

2. With the help of a non-invasive procedure, his primary care doctor and a cardiologist accurately diagnose the patient with “stable angina.” The cardiologist recommends a coronary angiogram—an x-ray of dye going through the vessels of the heart—with possible stenting of any narrowed arteries. “Stenting” is a procedure where a blocked artery is propped open with a tiny metal cage that is expanded in the vessel by the cardiologist. This high-intensity recommendation as a solution to a diagnosis the patient found only slightly troubling is not a surprise. Our instinct in medicine is not just to stand there, but to do something, even if we aren’t sure of its benefit. Doctors routinely overestimate the benefit of screening tests while underestimating harms, for example.

3. While the cardiologist is out of the room the patient looks up evidence on the effectiveness of stenting, such as this negative randomized trial from the Lancet (paywall), and concludes, many would say correctly, that it should not be first-line therapy for heart disease in most patients with stable angina who are not having a heart attack. Instead, the patient reads that aspirin, medications called beta-blockers, and cholesterol-lowering medications are first-line therapy.

4. The patient seeks a second opinion (we’re big fans of those at KBGH). Luckily for him, his second opinion comes from a cardiologist who is active in the RightCare Alliance, a coalition of patients and clinicians interested in bringing down the cost of medicine while potentially improving patient experiences. The second cardiologist agrees with the patient, who then loses weight, changes his diet, and experiences no more chest discomfort.

Here we have two stories, both of which had happy endings, at least in the evidence-based medicine sense. (Though the first ending was certainly not happy for the maintenance staff of my clinic.) But the journey to those endings was unnecessarily fraught. Patient One was convinced that he needed a device because of a slick ad by some unsavory device dealers. Patient Two, in addition to having “an inquiring mind and a smartphone,” in the words of David Epstein, lucked into seeing a cardiologist whose grasp of and willingness to follow evidence-based guidelines was superior to his peers. What ties these threads together? In a way, health literacy.

Enter health literacy

Health literacy is the capacity to process and understand basic health information in order to make good health decisions. High health literacy is associated with dramatic improvement in medical outcomes and a reduction in care costs. We’ve touched on it before at KBGH, and we even offer a health literacy product to members called Quizzify.

But what of the doctors’ poor decision making? What we call “health literacy” on the patient side, it could be said, we call “evidence-based medicine” on the physician side. Doctors are no longer reservoirs of information, as they once were; they don’t simply carry around information that their patients don’t have access to. The sum knowledge of medicine is far too deep and broad. Instead, doctors have transitioned into curators of medical information, sort of like librarians. And they’re expected to use their access to that information to make good decisions, ideally with the input of the patient, what we call “shared decision making.” But like anyone else, doctors’ decision making is influenced by outside forces. Doctors who own their own CT scanners, for example, are more likely than others to order CT scans. Other studies have shown that doctors who sell drugs to patients, like oncologists, are more likely to choose the more profitable drug more of the time. And simple human nature predicts that doctors who are able to “self-refer” for procedures, like cardiologists or surgeons who have the choice between low-paying patient education or high-paying procedures, will more often choose the procedure. This impulse, and the willingness of some people to pay for “doing something” may, in my opinion, explain some of the absurd, wasteful testing that gets done as part of executive physicals.

Health literacy in its classical definition is a way for patients to obtain and process health-related information. But in a broader sense—and I’m not trying to cast the patient-physician relationship as adversarial—health literacy can be thought of as the best way for a patient to defend herself from suboptimal decision making on the part of his doctor. After all, in the patient satisfaction study noted above, patients who were denied requested imaging studies or antibiotics were not significantly less satisfied. Why is this? An accompanying editorialist (paywall) notes that “Through Choosing Wisely and other campaigns to reduce low-value care, substantial attention has been devoted to preparing physicians to avoid frequently requested, low-value care such as these. We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs.”

Bringing it home

What we need, then, is a war with two fronts, manned by patients, doctors, employers, and payers who are willing to say “no.” (There I go with the adversarial language again). On one front, we continue to develop good health literacy in the general public, so that they can go to their doctor and ask for effective diagnostic and therapeutic strategies and decline tests or treatments they don’t think are in their best interest. But on the second front, we need to pay just as much attention to the “literacy” of physicians, employers, and payers, with the development of incentives that align with the well-being of the patient. One of the best ways to reduce low-value care, after all, is simply to stop paying for it.

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

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? 

Docs, you can get paid for ambulatory blood pressure monitoring

But it's not easy:

Pssst...wanna hear about quality improvement strategies in team-based hypertension care?

Then click here.

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.

Links for Tuesday, November 21, 2017: more on the new HTN guideline, Gymnastics coaches throwing robot shade, the last iron lungs, Germany bans smartwatches, and Raymond Chandler hated US healthcare

Thoughtful post on the new HTN guideline by Dr. Allen Brett

Representative quote: "Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person."

A gymnastics coach says the Boston Dynamics robot flip was a 3.5/5.0

'In a back salto, says Mazloum, “you want to be able to go as high as you can, and you want to be able to land as close to where you take off as possible.” To do that, the gymnast has to squat, throw her arms up by her ears so her body is a straight line (in gymnast-speak, opening the shoulder angle and the hip), then contract into a “closed” position again. By these standards, Atlas’ trick is “not the cleanest flip,” explains Mazloum.

Here’s Mazloum’s critique: Atlas didn’t quite get to that open position, “so it didn’t really get the full vertical that we look for. That’s why it went backwards a little bit.”'

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

If I understand this correctly, it is not because smartwatches cause kids to be distracted monsters (although I don't doubt that that statement is at least a little bit true). The decision stems from the capability of bad guys to hack in and monitor the location of little Dick and Jane:

You have to wonder who thought attaching a low-cost, internet-enabled microphone and a GPS tracker to a kid would be a good idea in the first place. Almost none of the companies offering these “toys” implement reasonable security standards, nor do they typically promise that the data they collect—from your children—won’t be used be used for marketing purposes. If there ever was a time to actually sit down and read the terms and conditions, this was it.

Get your shit together, parents.

Asking parents to destroy them might be a bit of an overreaction, though.

Raymond Chandler paints a dark picture of American healthcare in a newly-discovered story

The title, "It’s All Right – He Only Died," sounds like the title of a video residencies would show interns to convince them that quality improvement and patient safety are part of their job.

The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.

Madonna was framed in Body of Evidence. It's super hard to kill somebody with sex.

In the 1993 "erotic thriller" (everyone's favorite kind of thriller) Body of Evidence, Rebecca Carlson, played by Madonna, is taken to court for murder. Specifically, she's accused of having had rough or aggressive sex with a series of older rich men in order to cause their deaths. One survivor even says that she ended their relationship after he had heart surgery that made him healthier. Minor spoiler alert: she testifies on her own behalf and is eventually acquitted.

But her attorney, who she's been having rough sex with (natch), sneaks to her house after the trial and finds her with the doctor of one of her victims. The doc has coached her in how to kill men with sex. She taunts the doctor, who she's also been having sex with (natch), about how she can get him to do anything because of her world-class bedroom skills. When she tells him to get lost, he flies into a rage, eventually shoots her, and she falls out a window. I think there was some wrassling between the doctor and the lawyer in there somewhere. Aaaaaaaaand scene. At least that's how I remember it. I also remember some candle wax early in the movie, but I don't think it applies to the point I'm about to make. 

In a brand-new research letter in JACC (paywalled and not indexed by pubmed as of this writing), investigators studied 4557 cases of sudden cardiac arrest in or around Portland, Oregon, area between 2002 and 2015. Did I mention that Body of Evidence was set in Portland? Because it was. The mean age of the men was 65 years, which is prime Carlson Country, too.

They found that far less than <1% of cardiac arrest cases were linked to sex (34/4557, for an incidence of 0.28 per 100,000 adults per year). In 18 cases, the arrest occurred during sex. In 15, it was right after, and in one, the timing could not be determined. Only 1/3 of the people who had sex-associated cardiac arrests had any kind of bystander CPR. That's a hallmark of Rebecca Carlson if I've ever seen one. Also in the Rebecca Carlson tradition: almost 95% (32/24) of the sex-related cardiac arrests happened in men. The likelihood of a history of heart failure or heart disease was the same in sex-related and non-sex-related arrests. But men who had sex-associated arrests were on average five years younger than the non-sex-associated arrests. They were slightly more likely to be African-American, too. They note that an autopsy study in Germany came up with slightly higher risk, at around 0.2% of cases linked to sex.

So women: have all the high-intensity sex you want. You're safe. Men: If you're willing to roll the dice on your own personal Rebecca Carlson, the die is probably 100-sided, and you only die if it lands on the 100. Proceed accordingly. 

Should young, healthy people with type 1 diabetes take statins?

I encountered this question a couple months ago in a consult and intended to blog about it then, but relatively little trial data was available. I would have essentially been giving my own off-the-cuff opinion. That's very unsatisfying to me, and probably to the reader.

As background: we tend to think of type 1 diabetes as more a need for hormone replacement (insulin) than as a disease state requiring the complex management that type 2 diabetes requires. That is to say that type 1 diabetes, for all the unpleasantness it causes for people, is easier on the blood vessels as a general rule than type 2 diabetes. The ADA has a statement in its guideline that "For patients with diabetes aged <40 years with additional atherosclerotic cardiovascular disease risk factors, consider using moderate-intensity or high-intensity statin and lifestyle therapy." It's a category C recommendation, meaning it's mostly opinion and has a less-than-spectacular evidence base. It also doesn't differentiate between type 1 and type 2 diabetes. Similarly, a joint statement by the ADA and the AHA states that "Adults with T1DM who have abnormal lipids and additional risk factors for CVD (eg, hypertension, obesity, or smoking) who have not developed CVD should be treated with statins." Both statements argue against the routine use of statins in young healthy type 1 diabetics.

But a recent study from the New England Journal helps us with the question of statins in kids, and throws in ACE inhibitors for good measure. Investigators led by M. Loredana Marcovecchio and Scott T. Chiesa randomized 443 kids between 10 and 16 years with type 1 diabetes and urine albumin-to-creatinine ratios in the upper third of "normal" to some combination of ACE inhibitor, statin, and placebo. Creatinine is a consistently excreted product of muscle metabolism that serves as a nice comparator for other things the kidney excretes. So even if you drink a lot of water and dilute the amount of albumin in your urine, we can look at it compared to the similarly diluted creatinine and see if you're excreting too much.

Anyway: the investigators used a 2 x 2 trial design, meaning that there were ultimately four groups: placebo-placebo, placebo-ACEi, placebo-statin, and ACEi-statin. The statin was atorvastatin 10 mg daily, and the ACEi was quinapril 10 mg daily (after titration). They were most interested in the change in albumin excretion (that is, how much protein spilled through the kidneys into the urine). They assessed this according to that same measure, the albumin-to-creatinine ratio in the urine, from three early-morning urine samples obtained every 6 months over about two and a half years. They also looked at secondary outcomes like the new development of microalbuminuria (that is, the new appearance of protein in the urine), worsening of eye disease, changes in kidney function, blood lipid levels, and measures of cardiovascular risk. For the cardiovascular risk, they did ultrasounds of the carotids to measure the thickness of the vessels (carotid intima–media thickness) and measured levels of high-sensitivity C-reactive protein and asymmetric dimethylarginine in the blood. Both of these are generic markers of vascular risk.

After an average of 2.6 years, no benefits were found within the ACEi group, the statin group, or the ACEi+statin group compared to placebo. Unsurprisingly, the ACEi group had a much lower incidence of new microalbuminuria, but "in the context of negative findings for the primary outcome and statistical analysis plan, this lower incidence was not considered significant (hazard ratio, 0.57; 95% confidence interval, 0.35 to 0.94)." Also unsurprisingly, the use of statins resulted in lower cholesterol levels (including, unfortunately, HDL). But neither drug had significant effects on carotid intima–media thickness, C-reactive protein, kidney function, or progression of eye disease.

So we can take away from this small-ish study that, at least in a short amount of time in pretty healthy twelve-year-olds (the subjects were excluded if they had genetically bad lipid levels; the participants' average A1c was ~8.3% and their average blood pressure was 116/65 mmHg), there was no benefit to statins or ace inhibitors. This study will influence my recommendations to patients and other docs in the future. The kicker, naturally, is that many young people with type 1 diabetes have imperfect blood sugar control. What about those who can't get their diabetes controlled? It's a tougher call in that case, and this study didn't address it. 

Links for Wednesday, October 25, 2017: Leonardo and the aortic valve, e-bike smackdown in NYC, candy corn is disgusting but interesting, and McDonalds takes phones away

Leonardo da Vinci understood the anatomy and physiology of the heart better than the physicians of his day

He made wax molds of the aortic valve.

Based on zero deaths reported from e-bicycles, NYC mayor Bill DeBlasio is outlawing them. Super. 

He says not to worry, deliveries by car (responsible for 70 deaths in NYC so far in 2017) will still be available. I'm as skeptical of e-bikes as any long-time cyclist (mopeds and golf carts on the local bike paths cause me to mumble horrible things under my breath), but this is bananas. They should stay on the streets. They're smaller, slower, and infinitely safer to their surroundings than cars.

Candy corn, aka clown droppings, explained

Candy corn is disgusting. But this article is delicious. 

McDonald's is experimenting with locking up phoneworms' devices

My grouchy side says "Your pocket is just as good a place as the Fun Zone locker." My realistic side says that most of us lack the self-control to ignore a device that's in our pocket:

According to a survey of 302 parents conducted by McDonald's in Singapore, most (98%) say they use their mobile device whenever they're with family and more than two-thirds of them admitted using smartphones during meals. Most parents also said their kids use their phone during family time.

Links for September 18, 2017: American sperm, movement is life, neighborhoods and vascular disease risk, and Taiwanese fruit ghosts

Canada needs our sperm. America!

Background: It is illegal to pay for sperm donations in America's hat. 

"What Canada should do is legalize compensation for renewable bodily fluids in our own country. It would be the morally right thing to do. It would help make and save more lives, without harming anybody.

Until we realize our mistake, we need you Americans to keep rolling up your sleeves and unzipping your pants not just for the sake of lucre, but also for the sake of the thousands of current and future Canadians whose lives depend on you."

The more you move, the longer you live.

Bottom line up front (BLUF): Over 4.0 years of accelerometer use, total sedentary time was associated with an increased risk of dying. Not only that, but the longer the usual sedentary bout, the higher the risk of dying (roughly double for the highest quartile). This study is encouraging, in a way: you don't have to move that much to really affect your risk, you just have to move often. But this doesn't apply to you, dear reader, since you ride your bike to the grocery store and forsake social media. Don't you?

If you live in a disadvantaged neighborhood, the usual risk factors for heart disease probably underestimate your risk.

BLUF: In a group of patients from the Cleveland Clinic, the Pooled Cohort Equations Risk Model, or PCERM of the American College of Cardiology and American Heart Association underpredicted vascular disease risk in patients from disadvantaged communities (those with a high "Neighborhood Disadvantage Index," or NDI). For a patient from a disadvantaged community, the model only achieved a "concordance index," a measure of how well it predicts vascular disease, of 0.70. In Affluent communities, on the other hand, the concordance index was 0.80. That doesn't sound like a huge difference, but the NDI was much more powerful at predicting variation between census tracts than was the PCERM tool itself.

Fruit names do not invite ghosts, says Taiwanese government

"The seventh month of the lunar calendar is called Ghost Month, when the gate of the underworld is said to open and people prepare offerings for the dead.

People have refrained from offering bananas, plums, pears and pineapples, because the fruits’ names sound like they are inviting ghosts in Hoklo (also known as Taiwanese), the market’s Fu-te Temple (福德宮) chairman Lin Lai-fa (林來發) said.

In Hoklo pronunciation, banana sounds like “inviting” (tsio), plum like “you” (li), pear like “come” (lai) and pineapple like “prosperity” or “more” (ong), the combination of which sounds like an invitation for ghosts to stay in someone’s home."

Whatever, Taiwanese Agricultural and Food Agency. I've seen a Dragon Fruit. That thing's bound to attract demons.

Diabetes testing is for the [puppies and hoglets and billies]?

The Ad Council (with pro bono help by the ad agency Ogilvy) has released an admittedly adorable set of ads to encourage people to get tested for prediabetes. I agree with them in principle: testing for prediabetes is cost-effective in the long-term as long as it's paired with a lifestyle program that reduces the risk of advancing to full-blown diabetes:

 (mandatory conflict of interest disclosure here: I'm a consultant on a CDC 1422 grant that aims in part to increase screening, detection, and referral of pre-diabetic patients into the Diabetes Prevention Program)

Baby hedgehogs are called hoglets.

But unfortunately, the "testing" offered in these ads is probably far too sensitive. That is, it picks up too many possible pre-diabetes cases and over-diagnoses people.

The evidence for my contrarian stance is here:

Investigators publishing in JAMA Internal Medicine found that, according to a test very similar to the one in the commercials, almost 60% of patients over age 40 would qualify as "at risk" for pre-diabetes, and 81% (!) of those over age 60 would qualify. These numbers are clearly too high; the total population of pre-diabetic persons in the United States is about 86 million:

That's less than 30% of the population. Yet the puppies-and-hoglets-and-goats test says that almost twice that number is at risk. The United States Preventive Services Task Force, on the other hand, says that testing should be done based on only two factors: age (between 40 and 75) and Body Mass Index (25.0 or above). This is a more reasonable strategy based on risk of heart disease, but it unfortunately misses almost half of cases. Investigators publishing in PLoS Medicine found that, by looking at 1.6 years of electronic health record data from 2008-2010, only 45% of patients ultimately diagnosed with diabetes or prediabetes would have been screened under the USPSTF criteria. 78% of the missed cases would have been missed because they were under age 40, and 29% would have been missed because they were too thin, with a BMI under 25.0.

So what's the answer? The answer is to keep yourself from ever transitioning from "person" to "patient" in the first place. If you think you're at risk, based on the puppies-and-hoglets-and-goats test, a hunch, a past blood test, or a soothsayer, make a change. Jump into a new life and reduce your risk. It'll be cost-effective in its own right: Ride your bike to work. Pledge to eat only food that comes from the produce section without packaging for a month. Go to bed earlier at night. Give up bug juice for good. Make a change. And then, only after you've adopted the life you want and deserve, think about whether or not you want to get tested on your own terms.

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 24, 2017: Athletes and their pee habits, mobile farmers' markets, and surgery as a placebo

Athletes are very resourceful at finding places to go when nature calls

Bill Walker at Kansas State (hail alma mater) was well-known for urinating into towels on the bench. He's not alone:

Mobile farmers' markets are hitting the road.

Food trucks are a surprisingly durable trend. So maybe it's no surprise. 

Surgery is one hell of a placebo.

You should still avoid it whenever possible. The average American has eight (8!) surgeries in his/her life. That's too many. 

This doesn't happen naturally.

Anabolic steroids are an integral part of the bodybuilding scene.

Why does this matter? Because they make people die young. An astonishing fraction of pro wrestlers, who also abuse performance-enhancing drugs in large numbers, die before age 60, and they die of things we associate with androgen abuse: liver cancer, suicide, risky behavior, and heart disease.

Michael Oher, subject of "The Blind Side," cannot pass a physical because of concussions.

I'm short on the long-term future of football in its current form.

Do Americans spend on health care just because we're a nation of consumers?

I'm skeptical. I hold out hope that Americans, if given the right version of price transparency, might spend less. But this series of graphs is pretty convincing to Tyler Cowen's argument:

ADDENDUM (7/24/17 11:28 AM): Is the President fit?

I suspect the headline is a double-entendre, but at least in terms of physical fitness, the answer is very clearly "no." But I'm not sure it matters that much, especially in the context of the swirl of controversy that surrounds the rest of the administration.