Discipline is freedom

Spend even a little bit of time in the literature and blogosphere surrounding productivity culture, and you’ll read that “discipline is freedom.” Writers almost always attribute it to Aristotle, but he probably never said it, at least not in the context in which it is usually applied. And I know it sounds like what a dystopian government would print above the entryway into a forced labor camp. But its softer interpretation has some merit in medicine. Let me explain.

Many investigators frame the regulation of medicine according to scope. “Macroscopic” regulation, they say, comes in the form of payer policy, some of the things that Matt, Shelley, and I rant about in this post almost weekly.

“Microscopic” regulation, though, is where our notion of discipline may apply. It refers to things like safety initiatives and professional practice guidelines at the institutional and clinician levels. Take the “hemoglobin A1c” level, the nearly ubiquitous marker of diabetes control. If your personal physician adheres to the American Association of Clinical Endocrinologists’ guideline on diabetes, for example, he might treat you to a goal hemoglobin A1c level of ⩽6.5% for your diabetes. But if someone else’s doctor is a member of the American College of Physicians, she might aim for a more relaxed number for an A1c goal, like 7-8%.

A physician group seeing your employees should be able to defend their treatment target. I promise that they obsess over it in training and in evidence-based medicine conferences. But maybe more importantly, regardless of the physician’s treatment goal, he or she should be able to articulate how they intend for the patient to get there. Medicine now has a substantial body of evidence proving that structured treatment algorithms tend to outperform artisanal, patient-centered, off-the-cuff physician recommendations at the bedside. Sticking to diabetes as our example, we know that nurses and diabetes educators, following rules set by endocrinologists, tend to perform at least as well as doctors in getting patients’ A1c levels down to an acceptable range. We know that nurses outperform doctors in the treatment of gout when given a set of rules to follow. And in maybe the most famous example of this, we know that medical assistants operating in systems that give them rules and resources for the care of patients with high blood pressures perform astonishingly well (paywall), with control rates exceeding almost every other practice in the world.

The “discipline” here is the willingness of the nurses and medical assistants to follow rules set out for them by the care team. The “freedom” is the doctors’ ability in these systems to work as doctors. Instead of getting bogged down in the thick of therapeutic inertia, the doctors can focus on what they were really trained to do: diagnosing tricky cases, developing good relationships with patients and other providers, and designing treatment plans for the fraction of patients whose disease states don’t neatly fall into one of the algorithms.

Have you experienced any protocol-based care, such as chemotherapy, diabetes treatment, or management of things like gout or hypertension? We’d love to know your experience!

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.

Why You Should be Glad CMS Now Covers More Ambulatory Blood Pressure Monitoring

CMS covers more ambulatory blood pressure measurements now. Wait! Before you fall asleep–this is a bigger deal than you think.

Of all medical interventions available to physicians taking care of adults, blood pressure control may have the largest potential impact on lives saved. Since more than a third of Americans have hypertension, every 10 percent increase in controlled blood pressures nationwide would save something like 14,000 lives per year. And right now, less than half of people with hypertension have a well-controlled blood pressure. Going from 50% control to 90% control could be expected to save almost 60,000 lives per year. Part of the problem with getting there, though, is that measuring a blood pressure accurately is astonishingly hard. Some of this is due to obvious errors by the measurer: using the wrong size cuff, taking the measurement over clothes, and talking to you while they inflate the cuff, for example.

But some of the error is less predictable. A clever recent study (paywall) found that when participants in the SPRINT study, a large trial of very intensive blood pressure control, were seen by their own doctors during the study but outside the study protocol, their blood pressures differed markedly from the blood pressures obtained by the fastidious measurement techniques of the protocol. People in the “intensive” control group, in whom investigators were aiming for a blood pressure <120 mmHg, had a routine blood pressure at their own doctors’ offices that was 7.3 mmHg higher. People in the standard control group who were aiming for a blood pressure <140 mmHg had an average difference of 4.6 mmHg between their study blood pressure and their routine blood pressure.

Unfortunately, your own doctor may not be able to put in the time or workflow that it takes to get a study-quality blood pressure. She may not be able to let you rest for 5 minutes before a reading, or she may not invest in automated blood pressure cuffs. She may not have the time to average the results of three separate readings. But what your doctor could do is prescribe “ambulatory blood pressure monitoring,” or ABPM. ABPM is a technique by which you wear a device at home that periodically monitors your blood pressure, even at night, without any input from you. Then it sends the results to your doctor. Because the device is unaffected by the technique and timing issues above, it is considered the gold standard for the diagnosis of hypertension. But it has been historically very hard to get insurance companies to pay for. Getting payment required documenting a high likelihood of “white coat hypertension,” that is, a blood pressure in the doctor’s office that was consistently higher than blood pressures obtained outside the office on more than one occasion. People with “masked hypertension,” whose blood pressures outside the office may have been substantially higher than those measured at the doctor, were excluded.

A recent rule change by Centers for Medicare and Medicaid Services (CMS), though, allows expanded use of ABPM not only for suspected white coat hypertension, but also for masked hypertension. Since CMS is the bellwether for other insurers’ behavior, we can surely expect private insurers to follow.

So check your blood pressures at home. Or go to your local fire station or EMS. They can check your blood pressure 24/7/365 for free, and they know what they’re doing. See the image below to locate all the EMS and Fired Department stations in Sedgwick County, or download your own copy here. There is also an area where you can track your out-of-clinic blood pressures to report back to your physician.

If your home readings don’t match what you’re getting from your doctor’s office, ask your doctor about doing ambulatory blood pressure monitoring. Better yet, encourage your employees to ask about it.

Note: the Kansas Business Group on Health receives CDC funding to improve the detection and care of high blood pressures. But we believe in it either way.

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.

Use a Checklist for Your Checklists

I’m a big fan of physician-author Dr. Atul Gawande. Like, a big fan. Want evidence? Once upon a time the screen background of my phone was a picture of my wife and I with Dr. Gawande:

Just me, Atul, and Dr. Tracy Williams. No big deal. Eat your heart out on that plaid jacket, Pete Campbell.

My screen background is now a picture of my kids at a bike race (I’ve grown). Recently, and not because of garden-variety celebrity worship, I’ve been re-reading some of his 2009 book The Checklist Manifesto. I highly recommend it, and I thought I would share some of the lessons of the book that might especially resonate in the Time of Remote Work Due to COVID.

Gawande is careful to craft a message that a true checklist to help us accomplish involved tasks is not like your grocery list. It’s more like a catalyst to action, meant to free people up rather than restrict them. To help us write checklists that meet these needs, he recommends a “Checklist for checklists,” of sorts. Here are the parts that I find especially useful:

1. Try to define what kind of problem are you trying to solve. Is it fairly simple, like baking a cake? Is it complicated, like launching a rocket, where many, many things can go wrong? Or is it complex, like raising a child, where the inputs into the problem and the child’s response to them are constantly changing?

2. With the complexity of the problem in mind, what kind of list do you need? Some lists are more oriented toward “doing,” like baking that cake, while others are more oriented toward “reviewing,” like the pre-flight checklists in airplanes.

3. What kind of items do you need? Some checklists, like building an addition to your home, will require mostly actions. Other checklists, like preparing for a recurring meeting, are mostly communications.

4. Remove any items you assume list users will just do without prompting. In the process of compiling this I’ve deleted bullet points around identifying decision points and defining the problem. You already know to do those.

5. Identify the critical items and keep them. Consider emphasizing them by highlighting or installing alerts, such as on your phone if it’s a personal list, or on a poster or any software package the task needs in order to run if the list is shared among many, such as in the clinics we at KBGH work in.

6. Leave room for judgement. No one wants to sit through a meeting where the food for the office Christmas party (remember those?) is debated for an hour. Leave someone with a budget and any attendees’ life-threatening food allergies and see how she does.

7. Simplify the language if possible.

8. If the checklist is shared, adjust the order and layout for clarity if possible.

9. For checklists that have dire consequences, like the aviation checklists above or the preoperative checklists pioneered by Dr. Gawande, trial the list in real-world situations if possible before it goes into daily use.

10. Gather feedback from every potential user and refine the list based on that feedback. Dr. Gawande’s surgical checklist wasn’t just written and reviewed by surgeons. It was reviewed and modified by everyone involved in the care of the patient, from the orderly wheeling her into the room to the surgeon and anesthesiologist to the circulating nurses.

11. Maintain the list over time to keep up with its context. Checklists and clinic protocols require care and feeding just like your pets.

12. Treat the list as a tool, not as a religious tome. We at KBGH are fans of the care guidelines developed and used within the Kaiser health systems, such as this one for hypertension care (scroll to the bottom). But we know that a small number of patients will not be well-served by that care algorithm. That’s why doctors and nurses are trained to think critically.

13. Diffuse the list. Make sure it is available to everyone who may need it. That may mean posting it online.

Do you use checklists for complex tasks in your workplace? Let us know!

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.

Competent, compassionate, obsessives > whiz kids

On my morning bike ride today I rode up on a chunk of concrete that had fallen off an overpass onto the bike path. Somehow I've lost the picture of it, but no matter. I used WichitaReport to report it, and that got me thinking: the app is great, but simple. So much of what we get out of government is accomplished by compassionate, competent, experienced people--not stereotypical "whiz kids"--who obsess over solving difficult problems. Their work proceeds in spite of who leadership is (though the current EPA may be an exception). The result is that life gets better for the rest of us.

And then I saw this article on Kottke.org. 

Relevant quote: "When innovation does occur in city and state government, it looks small, boring, like the parts of life you don’t really want to think about. In some cases it doesn’t even look like innovation."

I don't think it ends at government. In medicine, the care that ultimately saves the most lives is routine (some would say boring) care delivered in anonymous health departments and clinics: immunizations, blood pressure control, diabetes screenings, eye examinations, and others. It's easy to do all these things poorly and astonishingly hard to do them well. But those of us who are lucky get the care of obsessive, compassionate nurses, doctors, pharmacists, and others who pay attention to details and competently treat around all the obstacles that come between us and good care.

This observation is so powerful that people have (rightly) started to think that we should put values other than raw intelligence, like emotional intelligence, at the top of our list of qualifications for medical school. It's worth a thought.

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

Then click here.

How do we engage practices in quality improvement?

From a 2017 grant meeting. Enjoy!

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”.

Links for Tuesday, November 7, 2017: hacking the genome, ammonia in the NFL, and community health workers for hypertension

Body hacker Josiah Zayner wants us all to use CRISPR to modify our bodies

And give ourselves cancer. I think he forgot the cancer part. From author Rowan Jacobsen:

"Let’s be clear: don’t try this at home! Although hundreds of gene-therapy trials are under way, and many experts believe they will eventually transform almost every aspect of human health, few have been proven safe. When you start scrambling your DNA, very bad things can happen. You can get cancer. Your immune system can attack the unfamiliar DNA, as happened when an 18-year-old with a rare metabolic disorder died during a University of Pennsylvania gene-therapy trial in 1999."

You may recall a link I posted to this guy giving himself a DIY fecal transplant. I'll give him an A+ for marketing. You can't beat the name Gut Hack:

NFL players have decided (not recently, it seems) that inhaling ammonia is performance-enhancing

Instead of something sinister, though, what the widespread use of smelling salts really reveals is the increasingly bizarre culture created by the NFL's (win-at-all-costs pressure cooker. Extreme parity, the minuscule margin of error, the constant threat of injury and million-dollar stakes all push players to exploit any shortcut, no matter how weird, gross or pitiful. More than a century ago in major league baseball, players like Hall of Fame pitcher Pud Galvin thought consuming ground-up monkey testicles was the answer (seriously). A decade ago, football found deer antler spray. Now it's smelling salts.

Not coke, but smelling salts in a cup. I think I would actually prefer ground-up monkey testicles.

More evidence that community health workers improve the care of certain patient populations

(paywall, but the abstract is free)

The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001).