Do Online Physician Ratings Actually Help?

Toward the end of my full-time clinical career, I attended a speech by a physician who encouraged doctors to “own” their online personas. He said we should actively manage our social media presence, our clinic websites, and our ratings by third-party sites like Angie’s List and Yelp. Against my instincts, I took his advice and Googled myself. Reader, I don’t mean to be histrionic. Many factors contributed to the end of my clinical career. But that innocent internet search did not, to put it lightly, make me excited to show up for work the next day:

I don’t share this anecdote as a bid for your pity. My experience with online ratings represents a tiny fraction of the “feedback” that a politician or a college football coach gets daily. I share the story as an entree to a question: do online physician ratings accurately reflect the quality of care people receive? If the ratings are accurate, then we should encourage our employees to use them. If they’re inaccurate, we should encourage employees (and practitioners) to ignore the ratings.

This is no idle inquiry. Some studies have suggested that up to 60 percent of patients consider online reviews important in choosing a provider. A recent national survey (paywall) of Americans aged 50 to 80, the heart of an internist’s practice like mine, revealed that more than 40 percent had looked up a physician’s rating for themselves at some time in their lives. Women, people with higher education levels, and (predictably) people with at least one chronic condition were more likely to have looked up a physician rating. The investigators in the recent study looked at several factors contributing to how prospective patients chose a physician, and online ratings came in only ninth, behind factors like “accepts my health insurance” and “convenient office location.” But the physician’s rating was still considered important almost as often as word-of-mouth reputation among family and friends, consistent with the results of smaller surveys.

But the ratings themselves are less influenced by clinical outcomes, like death, infection, or well-being, than they are by the patient’s experience. As we’ve blogged about before, denial of a patient request, especially for pain medications or lab tests, results in a dramatic decrease in patient satisfaction. That is surely poison for an online rating, regardless of the appropriateness of the denial. A very sophisticated study of dentist ratings showed that things like wait time were strongly associated with higher ratings, while raters barely mentioned clinical outcomes like infection or tooth loss. These experience-centric ratings may also reinforce biases that we already know exist. One study showed that, globally, male surgeons were rated higher on technical skills, while female surgeons were more highly rated for interpersonal skills.

It’s hard to tell if the ratings correlate with those harder clinical outcomes. A study of orthopedic surgeons’ online ratings found no correlation between ratings and total knee replacement outcomes. And one study found that the design of the rating website itself, like the presence or absence of advertisements for other doctors on the page, affected the quality of the data. But there is a hint of better outcomes in certain situations. A retrospective study showed that patients who had hip replacement surgery at hospitals highly ranked on physician rating sites did slightly better than patients at lower-ranked hospitals, for example.

If we can draw any conclusions from this muddled body of research, it seems that the most important lessons are, first, patients should understand the limitations of online reviews. A negative review of a highly skilled oncologist who has a gruff bedside manner may obscure the fact that his staff has experience in steering patients into clinical trials that may help complex cases. His staff’s skill may only be known by other providers. And second, doctors need to learn to use their online reviews as a source of quality improvement data. Someone who gives a doctor a lousy review may well have a valid complaint. The patient experience in American healthcare hardly has a sterling reputation. Instead of simply bristling at negative reviews, doctors should use the reviews as a tool to enact positive change.

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.

What's a Year of Life Worth?

Determining the value of treatment

You’ve probably heard the term “cost-effectiveness” thrown around in regard to medical treatments. In this blog we’ve made the case that much of the testing in “executive physicals” isn’t cost-effective, for example; we argued that the weird little tests that some executives get simply aren’t worth the money because they haven’t been shown to improve quality of life nor quantity of life, a measure we bundle into “quality-adjusted life years” or QALYs (pronounced “quollys”). But we’re not just picking on C-suite folks. When any new treatment, like a new pacemaker, costs more per QALY gained than the theoretical care its high cost displaces, like routine blood pressure treatment lost due to the extra cost resulting in nurses being laid off, the health of the population suffers.

Historically, even though the Centers for Medicare and Medicaid Services (CMS) have explicitly avoided setting policy according to cost-effectiveness for fear of rationing care, we’ve used Medicare’s payment for dialysis as an “apocryphal” benchmark. A year of dialysis in the early 1990s cost about $50,000. And without dialysis a person with end-stage renal disease will quickly die. So, the argument went, a year of human life must be worth about $50,000 and any new drug, therapy, or surgical procedure should cost no more than $50,000 for every resulting additional QALY. By this argument, a chemotherapy drug that adds five years to your life should cost no more than ~$250,000.

Other ways to use this model

This model based on precedent is far from the only way people have tried to define cost-effectiveness. A 2019 mathematical model found that Americans with an income of $50,000 should be willing to pay $100,000 for one additional year of ideal health. An extrapolation of patients in the United Kingdom’s National Health Service–where cost-effectiveness is tracked extraordinarily tightly–estimated that Americans would be willing to pay between $24,823 and $40,112 per QALY gained. A somewhat similar analysis comparing US health expenditures to other countries estimated $60,475 to $97,851 per additional year of life.

In an attempt to define a more home-grown, objective, US-specific threshold for cost effectiveness, David Vanness, James Lomas, and Hanna Ahn recently published a simulation to determine the number of people in a model population of 100,000 individuals resembling the US population who would lose insurance because of a $100 premium increase (1.6%, or $10,000,000 total for the population). They used 2019 premiums from the ACA marketplace as their baseline, and they were able to estimate insurance loss from historical data on coverage losses from the ACA Marketplace.

Next, using a study of mortality reduction observed with ACA Medicaid expansion, they were able to deduce the number of deaths among the newly uninsured in a year. To account for loss of quality of life among the survivors (since QALYs account for both quantity and quality of life), they benchmarked to a study on health-related quality of life by year of age.

Then the investigators ran a simulation with these “givens” 50,000 times. Here’s what they found: for each additional $10,000,000 in health expenditures passed through to patients as premium increases (remember, the equivalent of $100 per person, or a 1.6% increase), roughly 1,860 of the 100,000 simulated patients became uninsured. This resulted in five additional deaths, 81 QALYs lost due to death, and 15 QALYs lost due to illness.

So a new treatment costing the theoretical American population of 100,000 people $10,000,000 would need to increase QALYs by 96 to avoid reducing the overall health of the population. $10,000,000 divided by 96 equals $104,000 per QALY, about double the apocryphal $50,000 per QALY estimated by Medicare’s dialysis coverage.

What do you think? This is a question far better suited to the Halloween season we just left than to the Thanksgiving season we’re entering, but it’s a question we all have to ask ourselves: Is $104,000 per year a reasonable threshold for insurance companies to use in deciding on coverage of new drugs, tests, or services? Are you an Ebenezer Scrooge, unwilling to pay even $50,000 per year of life? Or are you a spendthrift, willing to pay more?

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.

Diabetes Education is Important. It's So Important That You're Already Covering It

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 burden of diabetes

34.2 million Americans—a little over one in ten—have diabetes mellitus, a group of disorders of glucose metabolism that causes a buildup of sugar in the blood. Diabetes is the leading cause of blindness, kidney dialysis, and non-traumatic foot amputation in the United States. The damage of diabetes isn’t limited to its physical or psychological burden. People with diabetes spend about 2.3 times as much on medical care than people without diabetes: $16,750 in medical expenditures per year, compared with $7,151 for non-diabetic persons.

Empowerment through education

In spite of the incredible disease burden and cost of diabetes, less than seven percent of people diagnosed with diabetes receive Diabetes Self-Management Education and Support (DSMES, or “diabetes education”) within a year of their diagnosis. This is a problem. Diabetes education is one of the most powerful interventions we have for keeping people with diabetes alive. One meta-analysis (a study that combines the data of several separate trials into one dataset) found that attending diabetes education reduced the hemoglobin A1c level, the measure of one’s average blood sugar over a three-month time period, by almost 0.6%, roughly equivalent to taking another daily diabetes medication. Another meta-analysis found that attending diabetes education cut the risk of death by 26%. If true, this is as powerful an effect on death as blood pressure control or treatment of cholesterol.

So the Kansas Business Group on Health is working with the Centers for Disease Control (CDC) to increase awareness of and referral into diabetes education programs. You’re probably covering diabetes education services for your employees already, whether you intend to or not. The Diabetes Coverage Act states:

“Any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization which provides coverage for accident and health services and which is delivered, issued for delivery, amended or renewed on or after January 1, 1999, also, shall provide coverage for equipment, and supplies, limited to hypodermic needles and supplies used exclusively with diabetes management and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such services and supplies under the law.”

The benefit is still subject to the usual deductible and co-insurance, and medical necessity requirements.

And we believe employers should be working to get their diabetic employees to attend diabetes education classes. It may prolong the lives of workers, and it may save you, the employer, money (paywall). If you are interested in starting a program through your workplace to get more of your diabetic employees into diabetes education programs, please let us help!

If you’re not ready to go there yet, but you’re interested in finding a diabetes education program in your area, visit here.

How Employers Can Address Social Determinants of Health

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:

What makes us healthy?

Modern medicine has something to do with it, and we should work to make sure everyone has access to good care. But visits to the doctor and the hospital probably only account for around 20% of health outcomes. Far more powerful predictors of health come from social and economic factors like family support and income, or from health behaviors like levels of diet, exercise, and smoking. So even countries with universal health coverage see differences in life expectancy between demographic groups, albeit smaller than those in the U.S. We call these predictors of health, the differences in conditions in the places where people live, learn, work and play, “social determinants of health.” They can be diced and divided a number of ways, but respected researcher Michael Marmot lists six categories: 1) conditions of birth and early childhood, like prenatal care and abuse; 2) education; 3) work; 4) the social circumstances of elders; 5) elements of community resilience, like transportation, housing, security, and a sense of community self-efficacy; and, 6) “fairness,” which he defines broadly as sufficient redistribution of wealth to ensure social and economic security and basic equity.

This can seem abstract, so to bring this idea home I encourage you to experiment with the CDC’s Life Expectancy Data Visualization Tool. You’ll see that the life expectancy in Wichita’s census tract 0027.00, centered on Seneca Street and Kellogg Avenue, is 67.1 years, far below the Kansas average life expectancy of 78.6 years. But go east to census tract 0073.02, centered on Rock Road and Douglas Avenue, and you’ll find a life expectancy of 83.8 years. Not coincidentally, the average income for census tract 0027.00 is $29,202, while the average income for census tract 0073.02 is almost three times higher, at $82,679. By my back-of-the-envelope calculations, traveling east from Seneca to Rock Road earns you an average of $8,488.41 additional annual income per mile and an additional 2.65 years of life expectancy per mile.

There are things we can do

That’s depressing. But what’s uplifting about thinking of health in terms of social determinants is that social determinants are modifiable. You can’t change your genetics or your family history of early heart disease. But you can, in theory, move to a safer neighborhood or get a higher-paying job or buy healthier food. And employers can help directly. Round two of what seems to be a revolving door of an infectious pandemic, as we’re experiencing now, may seem like a weird time to talk about this since many businesses are struggling even to keep their doors open and to hang on to essential employees. But I bring it up because COVID-19 has put a magnifying glass on the differences in medical outcomes between groups. Don Berwick has a powerful essay in last week’s Journal of the American Medical Association (paywall) in which he argues that due to political calcification, organizations–like your own company or employer–are possibly the best conduit for addressing social determinants of health, and they don’t have to be social workers to do it.

Help in some cases may be as simple as identifying employees that have been under-valued at your company and making sure they’re paid appropriately. People who make more money simply tend to live longer:

Taking care of employees also makes good business sense

This isn’t intended as a paean to socialism. It’s a strategy that may pay off for employers, too, and I don’t say that as a pointy-headed former academic. I’m simply repeating the case I’ve read in study after study. For example, in a well-known analysis in Harvard Business Review in the mid-aughts, researchers made the case that Costco, by paying its employees a higher wage with more generous benefits, not only had a superior, more stable workforce with less turnover than competitor Sam’s Club, but made almost twice as much money employee-for-employee: in the period of the study Costco made $21,805 in annual profit per hourly employee, compared with $11,615 at Sam’s Club.

Not everything is related to money. We know times are tight. If raises for certain employees aren’t in the cards, you could work within your own Human Relations department or with your employees’ physicians or payors to make sure your employees are screened for risk within social determinants, and it can be done via telemedicine. The University of California-San Francisco has compiled screening tools through its SIREN network. Your employees’ physicians may need some guidance with this. If so, tell them that they can document any positive findings and diagnosis codes from section Z55-Z65 in the ICD-10 catalog for billing and coding. If that seems too big a bite to take right now, organizations like 2-1-1 are ready to assist with local resources, even (or especially) during the current pandemic crisis.

If you decide to take on a project that aims for improvement in one of the social determinants, we are available to help with setting goals, managing progress, and measuring outcomes. Please get in touch with us as you move forward!

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.

Will technology save the aging primary care workforce?

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 issue we’re facing

The primary care physician workforce in Kansas–family doctors, internists, and pediatricians–is aging. Of the 1,976 primary care physicians in Kansas as of April 2020, 15.6 percent are already over 65, and 39.2 percent are over 55. The simple demographics of this are intimidating: even though they provide the most essential, cost-effective care in medicine, only 43 percent of practicing physicians in the U.S. are primary care providers, similar to the average of eleven Organization for Economic Cooperation and Development countries. But the fraction of graduating students entering primary care is steadily decreasing.  Even more ominously, older physicians are much more likely to be harmed by infectious diseases like SARS-CoV2, the causative virus behind COVID-19, adding to the inevitable workforce turnover caused by death. This all portends an uncertain future for primary care provision in many Kansas communities, since Kansas is already underserved relative to most other states at baseline.

As if that weren’t enough to worry about, physician skills appear to deteriorate over time. A 2017 study in the British Medical Journal found, for example, that elderly Medicare beneficiaries’ hospital adjusted 30-day mortality rates were 10.8% for physicians aged <40 and rose steadily to 12.1% for physicians aged ≥60, a 15% relative increase in risk for patients cared for by older doctors. Not only that, but costs of care were slightly higher among older physicians. This may not simply be due to age-related decline; it could be that younger doctors were trained in a way that improved their care. For example, “evidence-based medicine” is an integral part of medical training in the modern era. Older doctors who were not trained under this philosophy are demonstrably less likely to follow evidence-based care guidelines. This is hard for me to read. Statistically, I am likely a worse doctor than I was fifteen years ago. But I digress.

What can be done about this problem?

The Association of American of Medical Colleges, predictably, has argued for years that the solution is to train more physicians, by two mechanisms: first, the AAMC advocates for increasing the cap on Medicare funding that limits the number of residents at a given institution. Second, the AAMC supports greater incentives such as scholarships and loan repayment for primary care providers working in underserved areas. Examples of this are the Kansas Medical Student Loan Program, which pays for medical school for a limited number of students in return for an agreement to practice primary care in underserved areas in Kansas; and the Kansas Bridging Plan, which gives resident physicians additional funding during their training in exchange for a three-year commitment to practice in a rural community. On the federal level, the AAMC advocates for increased recruitment of international medical graduates, who already represent about a quarter of practicing physicians in America, through programs like the J-1 Visa Waiver program.

Others point toward increased use of non-physician practitioners like physician assistants (PAs) and advanced practice registered nurses (APRNs). This is clearly the preferred short-term option. PAs and APRNs require drastically less training than physicians, which eliminates the seven-year gap between policy and practice that we see in traditional medical training. And the health outcomes of patients seen by non-physician providers seem to be roughly equivalent to those of patients seen by doctors. Another British Medical Journal systematic review of randomized trials and observational studies–one of several such reviews in various journals, all with similar conclusions–concluded that “Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes.”

But long-term, if the skills of physicians like me decline with age, we can be certain the skills of other providers fall as well. How do we ensure that quality care continues to be delivered over the lifespan of the practitioner?

Automation may be the answer

Let’s look at my specialty, endocrinology. Six years ago, when I left full-time practice, the management of blood glucose levels was mostly an intuitive art/science, driven mostly by the experience of the physician-patient dyad. But in the last few years we’ve seen the emergence of “smart” glucometers that quadruple the likelihood of of a patient controlling their blood sugars while reducing their risk of dangerous low blood sugars. We’ve seen the development of automated insulin devices in the hospital that outperform conventional treatment of blood glucose levels. The FDA approved an artificial intelligence-based device to scan and diagnose the eyes of diabetic patients with diabetic eye changes (the most frequent complication of diabetes) without even having an ophthalmologist or optometrist involved. Newer, even more innovative, devices are in development, such as an app that can allegedly detect the presence of lung disease by the sound of a patient’s cough.

Some of these devices will pan out in the long run, while others won’t. But even a conservative projection is cause for optimism. It is not unreasonable to predict that practitioners with far less training than physicians will have the tools and skills to provide very competent care–elements of both primary care and specialty care–in the near future. Technology must be carefully monitored by humans, but its abilities do not decline with age. On the contrary, a given technology’s performance today is the worst that it will likely ever be. Best Buy will sell faster computers next month than it does today, and faster yet a year from now. And automated devices aren’t resistant to delivering evidence-based care; it is programmed in. I welcome the Rise of the Robots.

Is social distancing...bringing us closer together?

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:

If you’ve read as much as I have in the last few days about the COVID-19 pandemic, you’ve probably come across ominous-sounding warnings about social isolation or loneliness as a result of social distancing, our preferred short-term strategy to prevent the spread of the SARS-CoV-2 virus. Social isolation is the physical state of being alone, while loneliness is the feeling you get when your social interactions don’t meet your expectations; you can feel lonely in the middle of a crowded room, but you’re only socially isolated when you’re, well, socially isolated.

But both are bad for you. A 2017 systematic review showed that social isolation was associated with a 29% increased risk of death, while subjective loneliness was associated with a near-identical 26% increase in mortality. For perspective, a second meta-analysis in 2010 showed that “…by the time half of a hypothetical sample of 100 people has died, there will be five more people alive with stronger social relationships than people with weaker social relationships.”

As we have ramped up social distancing there has been legitimate fear that we would exacerbate the already-high rates of social isolation and loneliness, especially in elderly people. While it’s too early to say if that’s happening, I’ve been pleasantly surprised at my own experience. Just yesterday this meme came across my phone:

I found it so true. Now that many of us (but not healthcare workers, first responders, food delivery people, restaurant workers, mail carriers, or a hundred other “essential service” professionals and workers) are stuck at home during the day, it seems that we’re finding new strength and resilience just from getting out and moving in our neighborhoods and green space. I’ve talked to more neighbors on walks in the last three days than I had in the last three months, and not just because of warmer weather. Could it be that COVID-19 has begun a small restoration of what physician sociologist Nicholas Christakis calls the “social suite”: love, friendship, cooperation, and teaching, all from six feet away?

The evidence of increased investment in the social contract isn’t limited to the streets in my neighborhood. Young people are volunteering in large numbers to do things like deliver meals. So many retired doctors have offered to re-enter the workforce–at significant personal risk, considering many of their ages–that the Kansas State Board of Healing Arts has begun issuing emergency short-term licenses, and KAMMCO is issuing short-term liability insurance. Manufacturers in cycling, my favorite sport, are pivoting away from bike gear and toward the production of personal protective equipment. Congress is operating at a rare, near-normal level of functionality to give financial relief to millions of people (now if we could only get more testing resources). And I know that many of the readers of this blog, be they human resources professionals, insurance brokers, health administrators, or others, are working steadfastly to save as many jobs at their companies as they can in the face of an impending global economic catastrophe.

While you’re working hard on those things, don’t forget to work on these, too:

1. Look for ways to have “conversation-centric” interactions with people. Talk on the phone. Skype or FaceTime. Talk to people from your porch or from the street. As former Surgeon General Vivek Murthy says, “Smiling at someone–eye contact–is an act of service.”

2. Let kids around you continue to have unstructured play time with friends. Just keep them apart. Let them run around, ride bikes, and throw sand. Don’t let them wrestle or share toys.

3. If you’re still going to work, synchronize your coffee breaks with someone else. Common socializing like this has been definitively shown to be more restorative than snacking or emailing. If you can do it outside, even better.

4. Take time to express gratitude to others. Expression of gratitude is one of the most common indicators of life satisfaction in the US.

5. Volunteer. Organizational volunteering has been shown to be associated with a 24% reduction in mortality risk.

6. If you’re lucky enough to have some money to donate, do it. Spending money on others makes us far happier than spending it on ourselves.

Your Doctor Is Your Real Financial Planner

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Links for Tuesday, October 16, 2018: wine cheaters, tainted supplements, and stopping tractor rollovers

23 master sommeliers have been stripped of their title for allegedly cheating on the exam, and is there no one I can trust to tell me whether I’m drinking Mad Dog?

The candidates allegedly had insider info on the tasting portion of the exam, when they were expected to “clearly and accurately describe” six different wines, including grape varieties, origin, and vintage, in under 25 minutes.

I suspect (without any sommelier data to back it up) that this portion of the exam is poorly reproducible anyway. The American Board of Internal Medicine, but not other specialty boards, eliminated oral exams eons ago because of this.

If you’re taking an OTC supplement for sex, weight loss, or muscle mass, it’s astonishingly likely you’re getting a prescription drug mixed in with the sawdust

776 (!) tainted supplements were in the database from 2007 to 2016.

“Of the tainted products in the current study, 45.5 percent were marketed as aids for sexual enhancement, 40.9 percent for weight loss, and 11.9 percent for muscle building. They contained pharmaceuticals such as sildenafil, which is the active ingredient in Viagra; sibutramine, which is the active ingredient in Meridia, a weight loss drug removed from the market because of links to stroke and other cardiovascular events; and anabolic steroids or steroid-like substances.”

Original paywalled article here

Tractor rollovers are the #1 cause of death on American farms, but social marketing is a surprisingly cost-effective way to reduce death

Now if we could only use social media for good in other arenas…

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

Are triathlons dangerous?

First things first: I've never done a triathlon. I swim like a St. Bernard. But I've done a lot of endurance bike racing, and I've been at more than one event with a death, the most recent the 2017 Dirty Kanza. So I was interested that in the latest Annals of Internal Medicine, investigators looked into a sudden death database to identify 135 race-related deaths and cardiac arrests in American triathlons between 1985 and 2016. Interestingly, right at two-thirds of deaths and arrests happened in the swim part of races, which usually comes first, before the bike and run. The editorialists spend a lot of energy trying to link swimming to some special form of stress from cold water or other factors that might be extra-dangerous. But to me, the swimming link seems consistent with the finding that in autopsies, about half of subjects had cardiovascular abnormalities, most often old-fashioned atherosclerotic disease. Swimming caught most of these people simply because it was the first event. Had running or cycling come first, I suspect one of them might have been the death leader. I'm not convinced by their observation that most marathoners die toward the end of races; anyone who's seen the scrum at the beginning of a triathlon knows that it's inherently different than the often walking pace seen at the start of a marathon: 

From http://www.zwemza.com/?p=5515, triathletes tempting fate. 

85% of victims were male, but I'm not sure the significance of that number, since >60% of participants (at least in pro Ironman races) are male:

From https://www.outsideonline.com/1964906/fight-gender-equality-ironman

And if you look at total Ironman competitors, the distribution of sex comes much closer to the death/cardiac arrest statistics:

But sex aside, we're forced to see that cardiac arrest and death are not rare among triathletes. Between 2006 and 2016, their incidence was 1.74 per 100,000 participants in the study. The risk of death increased with increasing age, unsurprisingly. Don't let this dissuade you from being more active. The benefits of physical activity far, far outweigh the risks in almost everyone. If you're inactive now and thinking of becoming active, or if you're active now and thinking of doing really hard-core things like triathlon, consider taking the American College of Sports Medicine's new-ish algorithm to your doctor and talking it over before you hit it really hard:

We don't know how really weird stuff like performance enhancing drugs effects this. My suspicion is that it's not good. 

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.

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

Does metformin "promise" to extend life?

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

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

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

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

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

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

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

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

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

Is medicine a "low-impact" profession?

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

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

(link from slatestarcodex.com)

Monday, July 31 link-o-rama: good neighboring, CTE, mysterious illnesses, and drug-smuggling Mexican ultramarathoners

Is good neighboring good medicine?

A few weeks ago, I was asked to give a plenary at the Chronic Disease Alliance of Kansas, in part on emerging threats. One of the emerging threats I highlighted was social isolation, which increases your risk of death by about a quarter. The reason I brought it up wasn't the shocking statistic (we've known that for a while, and we know people spend more time alone as they age), but because we're now seeing a remarkable rise in the number of young men not working and filling their excess time with video games (covered in a previous link dump; near the bottom). I've become interested enough in the topic that I'm hosting a workshop on it at October's Intersections of Faith and Health conference in Salina. So I was thrilled to see James Chung's well-produced (as always) video looking at ways for local people to be better neighbors. If the data is to be believed, it could be a really powerful intervention.

John Urschel, NFL offensive lineman and erstwhile MIT math grad student, abruptly retired after the JAMA publication of chronic traumatic encephalopaty data (covered in a previous link to health).

He has something to fall back on other than football. Bold prediction: this is the start of a trend. Football will gradually become like boxing and attract mostly down-on-their luck types who don't have another option for income. Or the NFL will make wholesale changes to the way the game is played (just kidding; that'd never happen).

Living with a "none of the above" disease.

This article on poorly differentiated syndromes and the promise of genetics in solving them is (rightly) pretty hard on doctors. But I'm curious about what patients and families would like out of doctors who are presented with unsolvable conditions (unsolvable with local expertise, maybe, but maybe unsolvable altogether). When I was still in full-time academic practice, I saw 2-3 patients per day with chronic fatigue as their presenting symptom. I do not recall ever coming up with a unifying diagnosis for any of them, although we certainly found some previously unknown diagnoses. I would have been happy--thrilled, actually--to send them somewhere that had resources and expertise to look more closely at their disease states. But I just didn't know or didn't have the resources. And I know most of those patients left thinking I was a bad doctor.

The Tarahumara of northern Mexico, made famous by the book Born to Run by Christopher McDougall, are being coerced into smuggling drugs by cartels.

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. 

Spring link 5-pack April 26, 2017

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

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

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

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

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

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