Tim Ferriss - Lessons Learned

After reading the 4HWW, watching Tim Ferriss interviews and reading his blog, these are the action items I've implemented. The goal: a simple focused day with (very) few distractions.

• Stopped all pop-up notifications: those annoying outlook envelopes, gmail notifiers, IM pop-ups, and twitter device updates. The moment these appear you lose focus on what you're doing. No matter how good you are at multi-tasking, when you see that message appear on the bottom right of your screen, its in your head. That takes away from what you're doing in the moment. Check these things on your own time, twice a day or more depending on what your needs are, but don't let them rule your present time.
  

• Started a notebook of ideas: during the day we all have crazy ideas that pop into our head. Time-trending these by writing them down helps to figure out when your thought process is most clear. Also, I haven't written anything in what feels like ages. Writing is the mode of learning I grew up with and my retention is far better when I jot things down.
  

• Practiced being deliberately attentive: its easy to allow yourself to get distracted because there's so many things on your computer, desk, phone that draw you away. Forcing myself to stay on course with the task/project at hand has in fact made it more enjoyable. You can't force flow, but you can make an effort to avoid what leads you away from it.
  

• Began tracking what I eat: it seems like a hassle at first, but is really easy to do. I keep a log of all my meals on Google Calendar. Since you can see the blocks for each day next to each other, its easy to spot patterns in your diet. Its really helps me see when I veer away from the norm (whatever that may be for you personally).
  

• Minimized my taskbar: the amount of time I spend on the computer completely warrants this. As I'm working on one thing, I have a a habit of taking quick glances at the various screens that accumulate on my taskbar as the day goes on; Outlook, Gmail, articles, presentations, videos, etc. Having the taskbar hidden seems like such a small thing, but it has made an enormous difference in my "in the moment" concentration level.
  

We need a Medical Facebook

Deloitte's Health Care Consumerism Survey has some pretty interesting results. I think it attracted a biased sample of consumers though, mainly because of this finding: 1 in 4 consumers maintain a personal health record. I find that very hard to believe, especially when the word, "maintain", is used. "Started", "created but never used" would be more fitting.

PHRs are ubiquitous - hospitals, insurers, popular medical websites all provide them - but people rarely use or update them. You put your information in, register a login and never look at it again. Why? Because its not connected to anyone. Even with all your medical info in one place, you don't have the ability to share that information very easily. Docs have to know about it, support it and use it in order for it to work. Otherwise, its just a Facebook profile without any friends!

Here's another reason why PHRs won't take off any time soon:

"Tethered" means linked only to a provider or a hospital and "standalone" refers to a web-based service like WebMD or Microsoft's HealthVault. Its hard to build a Facebook, let alone a medically-based version with all the privacy/security issues involved. The need is obviously there. PHRs won't take off without it.

EDIT: Doctors don't trust PHRs because they don't link to anything they use on a regular basis. Get connected!

Worker, Interrupted

"Want to get something done? Turn off Twitter. Turn off Facebook. Turn off blog comments. Turn off FriendFeed. Turn off Flickr. Turn off YouTube. Turn off Dave Winer’s blog and Huffington Post. Turn off TechMeme.

Turn off the distractions."

--Robert Scoble

After reading the above from Scobleizer's productivity post, I of course looked up all the references I didn't know and lo and behold I was signing up for another Web2.0 application. Classic.

Yet this also gave me insight into my own assimilation within the grab-and-go, click-through culture that's been rapidly developing over the last decade. Procrastination-induced internet escapism is an easy habit, and at the sake of projects and work. Reading may broaden one's perspective, but it doesn't lend to daily, efficient production. What Csíkszentmihályi describes as flow.

Mastering information, i.e. diligently taking notes to be referenced later and forever committed to our personal knowledge bank, is infrequent in today's look-up-on-wikipedia, web-bite world. Rather, we take snapshots. Into fields, philosophies, lives, ideas, hobbies and even vocations. We don't really know these things, but we feel like we do. Vicarious information gathered and stored in bookmarks on del.icio.us or google notebook make up our reference libraries now. Learning doesn't happen through osmosis though. And the doing must be done (channeling some Yogi Berra here!). Keeping pace with our reading/browsing through personal accomplishments, whatever they may be, is important so that when we look back we see our own contributions among the multitude.

Marc Jacobs on Simplicity

“The thing I love about the gym is not having to make choices,” he notes. “My trainer says, ‘You’re gonna lift this; you’re gonna do that ten times.’ Okay, great—just tell me what to do and I’ll do it. It’s the same thing with my nutritionist. All I have to do is follow instructions. I love that. This is not about ‘Would it be better in red or blue?’ There isn’t a lot of abstract, circular thinking involved. And it’s great. Those times are really nice for me.”

--Marc Jacobs from this GQ article

Bloggers Galore!

I spend a whole bunch of time reading a wide variety of blogs. So much so that (like email) I had to force myself to limit my blog reading to specific times during the day. A quick check of google reader can sometimes lead to a 2 hour wayward session out in the blogosphere. Below are a few bloggers I keep up with and mostly discovered through my random traverses.

1. My friend, Deep, started blogging around the beginning of the year. She offers a unique, personal perspective on (actually living) life as a med student. Her idea of doctors using twitter to keep in regular touch with their patients is just brilliant!

2. Cameron's commented on my blog several times. His blog is filled with pointers on relationships, fitness, and life in general. Here's one of my favorite posts.

3. If you're interested in health care IT, John Halamka's your man. He's professionally involved in an array of things, from being a CIO of a hospital system to ice climbing to playing the Japanese flute. This post gives you a humorous, insider perspective into what he's all about.

4. Jason Shafrin, the healthcare economist, is running a great segment comparing health care systems around the world. If you're interested, here's France, the first in his series.

5. If you can keep up with Tyler Cowen, then subscribe to marginal revolution. His interests are varied, but the common theme is economics. I learn something everyday from his posts!

Monday Afternoon Recap

Here's a few interesting things I came across over the weekend & this morning.

1. Hospital Compare went up late March. See if your hospital is there. The site still has a long way to go though on useful metrics.

2. Study finds link between drinking and breast cancer (for post menopausal women). I'll give this finding about 2 years before its refuted. I have no clinical research experience to speak of, but research news over the past 5 years certainly doesn't boast a great track record.

3. It was hard to miss this article on rising co-payments for drugs if you opened up the NYTimes this morning. The anecdotes are disheartening and the sad fact is that after decades of highly subsidized drug prices, we're only now being faced with the real costs of innovation. Longer life and better health come with a big price tag.

4. On a lighter note, check out Clear, an ezpass for airport security!

5. Also, I saw this on a friend's key chain the other day. What a great way to keep your favorite pictures with you all the time. And its cheaper than those wallet-size shots!

Why not showing up to your doctor's appointment is such a big deal

No show rates for doctor's appointments are frustrating on all counts. Patients who don't show up are most likely not going to get rescheduled for another 4 weeks due to a consistently packed schedule. The doctor could have gotten another patient in and if known ahead of time, another patient waiting to get in would have taken the empty slot.

Solving this problem has always been a slippery slope. Charging patients a fee for not showing up or failing to cancel 24 hours prior to the appointment can seem antagonistic and turn patients off to your practice. Yet letting a few patients continue their lax or tardy behavior at the sake of not providing care for those that are in need can be costly as well.

There are ways to solve this problem that satisfy both patient and doctor. What got me on this topic in fact was an article that described one really innovative solution:

"We added a new doctor - first name "Virtual," last name "Physician" - into our scheduling database. When our habitual no-shows scheduled an appointment, we place them on Dr. Virtual Physician's (or Dr. VP, as we have come to call it) wide-open calendar. The primary care physician's schedule is not affected by the chronic no-show's appointment. If the no-show patient does appear for the appointment, they are placed in the queue behind the on-time patient."

EDIT: Doctor's offices do get walk-ins (GPs, Pediatrics, etc.), but the timings are never predictable. Regardless, keep in mind that doctor's offices keep very static schedules. A lot of practices use the virtual scheduling solution above to block off times daily or on Fridays for catching up on administrative activities. The reason they don't just fit it in when a patient doesn't show up is because the expectation is that there is a real medical reason for the visit and many potential medical reasons for a delay. So time lost due to a no show is all real time.

Why are the Insured Crowding ERs?

Emergency departments (EDs) are almost always overcrowded and a new study sheds some light on the who, the how and the why. The increased number of visits from the mid '90s to now are in fact coming from insured patients who have access to a usual source of care (PCPs)! Visits by the uninsured, who would normally be considered the more likely culprits, have actually stayed stable in the past decade.

This is really important on the policy end, considering universal health care (if enacted) may exacerbate, not reduce the ED overcrowding problem. Also, if the uninsured aren't the main concern behind this issue, safety net funding for bad debt may take a hit.

But back to why the insured might be responsible for more visits in the ED. The authors say the

"increase in ED use may be attributable to lack of ready access to primary care and other structural problems in the health care system."

Structural problems such as long waiting times for appointments, lack of relevant patient info such as medications and prior medical/surgical history, sub-par diagnostic and treatment capabilities, and poor post-visit communication between patient and their PCP. This is really disconcerting since EDs are being filled up with patients who have minor complaints or illnesses, thereby diluting triage meant to prioritize those with urgent needs.

Looks like there's a lot of work cut out for all of us in health care.

EDIT: In regards to Di G.'s comment about clarifying how insured patient's actually wind up in the ED, here's one elaboration. Say you're experiencing horrible stomach pain and your PCP is out of town. You go to another doc to get a referral for a GI specialist. The new doc has no history of your prior history of bulimia or the gall bladder operation you had a couple years back and now neither does the GI guy. The GI doc, unaware of the lack of your medical information, sees you and when you're prompted to provide information about the meds you're on, you have no idea and start listing the colors of the rainbow you see every morning in your pill box. Your prior history is incomplete, you don't know what meds you're really on, and you're pretty high on the pain scale. You're an easy triage to the emergency department regardless of who sees you. But in the ED, the triage nurse will most likely put you towards the bottom of the list after the gun shot wounds and car accident patients. Hence, the 4 hour wait.

Electronic records are just one part of the solution. More importantly the flow of information from one site to another is the key to making this all work. The VA does it well, but most other clinics use different vendors that don't talk to each other.

Real-time Tap

It would be really nice to have some way of knowing the minute details of certain events real-time. I'm thinking along the lines of wait times for gaining entry into a live show or sporting event, travel times and actual timings for airport shuttles, delay alerts for traffic and flights, stadium seating availability due to cancellation or no shows and so on.

With a smartphone, you can access the web and look up the time and location of an event via its related website (if there is one). But that's a static, passive way of communication. We need some way to automate that friend who gets there early and calls you about a long line, a delay, or a saved seat.

Dysfunction junction, what's your function?

What's the deal with Southwest's boarding policy? I just can't find a reason for it. I'd heard about their alphanumeric system of boarding passengers by groups A, B and C in that order with a # attached to indicate your location within the group, but experiencing it was similar to what cattle must feel like when being prodded to pasture. And I was in group A!

I got the seat I wanted, but that would have been the case with any other airline, as long as I booked early. Southwest fills the niche of booking anytime and checking in early (which is why they constantly overbook and have to make concessions). If I hadn't checked in exactly 24 hours prior to my departure time, I wouldn't have gotten the seating group I did. If Southwest doesn't believe in first or business class, then simply get rid of it and let people pick their seat when they book and see if they can grab a better one based on availability at the airport (like JetBlue does). In fact, the system is so dysfunctional that websites started popping up to automate early check-in for a fee. Gaps in efficiency get closed and Southwest has fought well and hard to block these websites from closing them. But why bother when you can just spend the money on creating an efficient process in the first place?

Back to the Past

I booked a cruise to the Bahamas recently, and I can't begin to tell you what a hassle it was to go through the process. I need a vacation from booking my vacation!

I would love to go to someone and say, "this is where I want to go, this is what I'm willing to pay, take care of the rest." Oh wait, it's called a travel agency! And they're all going out of business because we have the convenience of doing everything ourselves through orbitz or priceline or travelocity.

But price shopping is anything but convenient. The initial thrill of beating the big hotels wears off pretty quickly. And then you have to keep a log of all the confirmation #'s, hotel phone #'s, travel regulations and...well, that's another blog post on travel organization.

Looks like there may be a reemerging niche for travel planning. Or maybe just hiring a travel websites expert. Either way, extend your hours AAA!

In Want of Need

“Is there any other industry in this country which seeks to presume so completely to give the customer what he does not want?”
--Rupert Murdoch

Sometimes leftovers just sit in the fridge, not because you don't want them, but because they're in the back of the fridge. If you keep fruit out on the table instead of a cookie jar, you're more likely to eat fruit. And if you make it appealing, say by putting a variety of bright colored fruit on the table, you'll be even more likely to grab something on the way out the door.

Availability is extremely important in changing habits. Marketing is all about spending lots of money to get a product in front of you. Once you see it, you start thinking about price and quality, but whether you need it is lost in the novelty and appeal. Most of our cultural mores and definitions of beauty are shaped this way. I can't help but think that Rupert Murdoch preferred seeing really skinny, attractive women on TV, which left us a culture of eating disorders and a single-minded warped sense of beauty. Its remarkable!

But if big corporations and marketing firms can psych you out to want what you don't need and like what you never cared about, so can you. Put that fruit bowl on the table, maybe along with some oatmeal in your pantry, and sugar-free juices in your fridge. Avoid TV for a week and see how you feel. Go grocery shopping with a list in hand. Work out a personal budget and use cash more. The tips are endless and you've heard them all before. But there is truth in cliché and when you're better off because of it, it doesn't matter what you call it. What matters is that it works.

The Closing Flood Gates

"In any great organization it is far, far safer to be wrong with the majority than to be right alone."
--John Kenneth Galbraith

We all love specialists. Patients know exactly what they go to them for, they've seen the problem hundreds of times in a given month so they have a pretty good idea how to treat you, their offices have 42" plasma TVs not magazines, and they attract the cream of the med school crop so you know they're good. But who gets you to see them?

PCPs! They're the referral centers. The gatekeepers to the rest of health care industry. And soon they'll be in pretty dire straits. Just go to the AAFP policy page, and you get an idea of all the Federal advocacy issues they're involved with. People flock to where the money is, but in this case the monetary incentives set up for the specialty docs and against the primary docs may not actually be beneficial to our health.

Insolvency or plain old not having the money

"Without change, rising costs will drive government spending to unprecedented levels, consume nearly all projected federal revenues and threaten America's future prosperity."
--Treasury Secretary Henry Paulson

The dates in this NPR news article are just scary. 2041 for Social Security. 2019 for Medicare. According to program trustees, those are the forecasted years when the trust funds for each benefit program run out. "Depleted" and "wiped out" were also particular terms chosen by the author of the article.

But I thought Medicare Part D was just approved just a few years ago? How did it get budgeted in? And what about the privatization debate for social security? If the gov't can't support us (or needs to exorbitantly raise tax rates to do so), maybe we should be allowed to invest for ourselves.

The healthcare economist elaborates further on the Medicare end.

Weekend Smörgåsbord

1. Tyler Cowen's link to RateMyCop.com

2. TEDBlog's mirror therapy for phantom limb pain

3. DMX on Obama (Ctrl+F "Obama")

4. Calculating your RealAge

5. Slate on the 25th Amendment loophole: 2 presidents for the price of 1!

A Mortgage-Backed Life

As I'm washing dishes today, I'm constantly thinking of what I have to do next. Go to the bank, get a car wash, go workout, get something to eat. The list continues. I'm on autopilot with my shoulders shrugged and brow creased. Getting to the next thing is more important than what I'm doing now. I'm not enjoying the process.

We always seem to be trying to get to the happy and fun moments without giving much thought to what we're experiencing now. So often I hear "just gotta get through the day", or "same shit different day". Your job or whatever you're trying to get out of the way may be terrible, annoying, or boring, but its the attitude you have towards it that'll make it easier to handle. Unless you have an alternative (which, if you did, you would grab right away and not complain), the task still has to be done.

Owning what you do always helps. When you really personalize something, make it your responsibility, realize your name will be on it, you start paying more attention. Think about owning a car or house versus renting either one. You just take better care of the thing you own because ultimately its you who'll have to fix it if something goes wrong. Even with such a simple thing as washing dishes, if you say to yourself, "if I don't pay attention to this and do it well, I'll be eating out of a dirty plate and might get sick", you'll be that much more focused.

I read about this "ownership perspective" a long time ago when I was perusing books that helped you narrow down your career choice. One of the books kept bringing up the fact that no matter what you choose to do, from engineering to auto sales, own that job and make it yours. Don't go in thinking you're getting paid to work. You're renting yourself (your human capital) out. Go in owning that job! Think like the owner and see what you can do to improve the place, ask questions, make suggestions, get a comment box going, whatever gets you involved.

Applying this point of view to your career is too big of a start. Keep it simple. Now how many things popped in your mind while you were reading this? Start there...

The oh-so-close horizon

Vista (vist-uh) n.

1.	a view or prospect, esp. one seen through a long, narrow avenue or passage, as between rows of trees or houses.

2.	such an avenue or passage, esp. when formally planned.

3.	a far-reaching mental view: vistas of the future.

Have you noticed how the word, "vista" has been popping up everywhere?? Considering definition #3, I understand why and it makes even more sense in the corporate view of things. Strategic planning meets Marketing, right? Here are a few more instances:

• WorldVistA
• AmeriCorps VISTA (Volunteers in Service to America)
• the Rx variety of course...Evista
• and c'mon now...Windows Vista

It's About Time

Time Out of Mind is simply a wonderful article. Author Stefan Klein makes a strong and articulate argument against the notion that "time is money".

"Believing time is money to lose, we perceive our shortage of time as stressful. Thus, our fight-or-flight instinct is engaged, and the regions of the brain we use to calmly and sensibly plan our time get switched off. We become fidgety, erratic and rash.

Tasks take longer. We make mistakes — which take still more time to iron out. Who among us has not been locked out of an apartment or lost a wallet when in a great hurry? The perceived lack of time becomes real: We are not stressed because we have no time, but rather, we have no time because we are stressed."

After taking a couple of economics courses, you invariably come to realize that the "cost" in opportunity cost is in fact stress. Applying the "no free lunch" principle makes perfect sense when you're making a calculated decision on which alternative might be best for the growth of your business. But does it realistically apply when you're calculating your free time in terms of dollars? "My free time is worth _______." Its really not, because its free! It only costs as much as you think it does. Hence the stress.

Quick elaboration. Suppose you get paid $10/hour and all your overtime is pre-approved. Now you have to valuate every extra hour beyond 8 hours as being worth $10, otherwise you lose it. Therefore, any activity you might choose to do outside of your work time has to be worth more than $10 to you. But what if you take a break because you're tired? Or go grab a sandwich? Or just do nothing? Some might say that these activities make you more productive and energetic allowing you to work more hours later. That's one possible rationalization. But is it even necessary?

The moment you choose to pursue an activity outside of work, your acceptance of the cost is intrinsic in your choice. Borrowing from economics once again, that cost is sunk. If you decide to focus on it, you only end up causing yourself stress above and beyond the $10 you already decided are worth losing. So then, would it be appropriate to say that opportunity cost is in the mind of the perceiver?

Trendy Disruptive Marketing

Dove's self-esteem fund sponsors the two videos below. If you haven't seen them yet, they're definitely worth a couple minutes of your time. There's been a lot of debate about whether this is some sort of "altruistic" marketing to fuel sentiment against mass media depictions of women.

Keep in mind this is marketing. Just like any other company selling any other product. But Dove has caught on to all the female angst that's been building up over the past few decades against the fashion, diet, exercise industry to make us all look like twigs. And why not? It does in fact sell:

"According to Information Resources, Inc., sales of Dove soap brands grew 7% to $281.3 million from Jan. 1 to Nov. 5, 2006; Dove hair care products sales grew 13.3% to $102.5 million; and Dove skin care products and lotions grew 16.2% to $117 million in that time period. Unilever posits that one in every three households uses a Dove product."

EVOLUTION


ONSLAUGHT

"The Thing To Do"

"Our leading men are not of much account and never have been, but the average of the people is immense, beyond all history. Sometimes I think in all departments, literature and art included, that will be the way our superiority will exhibit itself. We will not have great individuals or great leaders, but a great average bulk, unprecedentedly great."
--Walt Whitman

Whenever someone says "its the thing to do", I usually cringe and think exactly the opposite. Its not that I don't want to do what everyone else does, or that I'm above it in any way, but I'm instantly mystified and skeptical at how so many people can agree on one thing. Back in the 80's it was the thing to wear bell bottoms, and we all know how badly that went.

But now, its become a great mass marketing scheme. An iPhone, a big-screen tv, facebook, having a USB-drive hanging off your key chain are all considered chic and nouveau. Taco Bell (insert any generic fast food chain here) features a new special and its the thing to do to grab one. Even the coming election suffers from this phenomenon. Obama is the guy to want to vote for. Whether any of the above are sensible or not makes no difference. They're just the things to do.

Then again, making a well thought-out decision backed by unbiased research is very difficult these days. Who has the time for it? We outsource this kind of brain power to the Al Gores and Malcolm Gladwells of the world, hoping they took the time to do it right. I don't have the answer, and going against "the thing to do" just because it is isn't right either. All you can really do is be aware of peer pressure, groupthink, and the bandwagon effect. Once you acknowledge the mass mania, its much harder to get caught up in it. But its just a start. Then comes the hard part; personal justification.

Google Health Teaser

Google recently developed a partnership with the Cleveland Clinic to test its Google Health application.

Today, Google released a few teaser screenshots!

Modigliani-Miller Theorem Explained

"Think of the firm as a gigantic tub of whole milk. The farmer can sell the whole milk as is. Or he can separate out the cream and sell it at a considerably higher price than the whole milk would bring. (That's the analog of a firm selling low-yield and hence high-priced debt securities.) But, of course, what the farmer would have left would be skim milk with low butterfat content and that would sell for much less than whole milk. That corresponds to the levered equity. The M and M proposition says that if there were no costs of separation (and, of course, no government dairy-support programs), the cream plus the skim milk would bring the same price as the whole milk."

- Merton Miller from "Financial Innovations and Market Volatility"

Should your PCP be your Friend?

“The real price of everything, what everything really costs to the man who wants to acquire it, is the toil and trouble of acquiring it.”
--Adam Smith

It depends on if you think your car mechanic should be your friend. You see either professional about as frequently, mainly in times of distress. But the key difference is that your primary care practitioner (PCP) is your gatekeeper to the rest of the medical world, so it is worth your while to develop a strong relationship with one. You'll realize just how important this r'ship is when you move out of town, change your insurance, and oh yeah, get sick.

PCP shopping is essential. I just posted about the website, Vitals, which helps you do just that. There are many other sites that do the same, including the one your insurer most likely provides you (the most important!). You'll get a pretty long list of internists, family practitioners and general practitioners in your area and pretty soon you'll be scratching your head wondering just who to go to. Its pretty hard to compare doctors the way you compare cars and electronics. There's no consumer reports for physicians...at least not one that's agreed upon. But in general, keep in mind the following when making your choice:

1. Call and see how long the wait is before the next appointment. If its longer than 3 weeks, they're either really good or really inefficient. Double check if the doctor is on vacation or on service at a local hospital. That should give you a better idea of how they allocate their time. Then its up to you if you want someone reputed or someone reliable.
   
2. If you do choose the busy doc, ask who will take care of you instead when you absolutely have to come in. It could be another doctor, the head nurse or a resident. Either way, you have that much more information to work with.
   
3. Ask the secretary for a recommendation, then call again the next day and ask a different secretary. See if they'll let you speak briefly to a nurse and get her recommendation. This'll also let you know if they do phone consults either with the physician or the nurse. This way you can get triaged in quicker when you're sick.
4. See if they have an electronic medical record (EMR). This indicates many things about the practice; they're up-to-date, they're willing to spend the money to stay that way, and they want to be organized.
5. What about a website?? Do they partner with your preferred pharmacy? Can you refill your prescriptions online? Make an appointment online? Get test results online? Do they provide a personal health record (PHR) to help you organize your own health record and communicate your problems as they're happening?

Notice how none of the above goes into quality of care or bedside manner. There's very little out there to provide you with such metrics...again, its forthcoming. Who would've thought picking a doctor would be such a chore!? But its like anything else. You get what you put into it. And that all depends on how you answer the question above.

Get your Vitals Taken

George Van Antwerp posted a positive review for this site, Vitals.com, and I have to agree with him. I looked up some of the physicians I had worked with in the past and found out more about them than I ever knew before. It was startling at first to see their age, years of experience, and where they went to college. Then I started thinking about the ever-steady finding that more experienced physicians are simply better practitioners, so why shouldn't patients be aware of these characteristics?

Anyway, overall the site is really user-friendly. You can find a doc, figure out who to see for your problem and even rate the physician after your visit. Now it just needs critical mass.

More Rhetoric, Little Evidence

"When you encounter seemingly good advice that contradicts other seemingly good advice, ignore them both."
--Al Franken

This Valentine's Day NEJM article, "Does Preventive Care Save Money? Health Economics and the Presidential Candidates", speaks for itself.

"Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical. Such analysis could identify not only cost-saving preventive measures but also preventive measures that deliver substantial health benefits relative to their net costs; this analysis could also identify treatments that are cost-saving or highly efficient (i.e., cost-effective)."

A visual always helps too:

Capitalism Entrapment

"The power of vested interests is vastly exaggerated compared with the gradual encroachment of ideas."
--John Maynard Keynes

I don't think there is such a legal term, but there should be. Or even better, it should be in the DSM-IV.

Capitalism's primary tenet is to promote efficiency in the interaction between buyers and sellers in a given market. Nobody really cares who is doing the selling or buying as long as they continue (and never stop) doing it. Its about the product, not the person.

I'm specifically thinking of Britney Spears. Young, talented and pretty, she makes it big on the world scene when she's 17 and now, a failed marriage and two kids later, she's suffering from a major drug problem. And selling. She sings about her problems and sells. She sings about being able to sell even though she has problems...and sells! We don't care about what's going on with her personally, we just love her music. She's enrapturing. She's entrapped.

The right or wrong of it is never clear. You can point to Bill Clinton's infidelity or Robert Downey's Jr.'s addiction or Ken Lay's corruption. But it depends which side you're on, the side that made money or the side that didn't. And money has the tendency to blind people to the hypocrisy in others' actions.

Bottomline is that as mega corporations continue to drive the mom's & pop's out of business, there's a growing disassociation between the seller and the product. To condone the behavior we want, we must ourselves live and breathe it. Eat better and exercise more if you want to curb the obesity epidemic. Become a socially responsible investor to avoid blindly funding oil, cigarettes, and fast food. Take responsibility and make yourself accountable for it, because everyone learns by example!

EDIT: How could I forget Martha Stewart!?

YOU determine the Value of YOUR Health Care

"Men occasionally stumble over the truth, but most of them pick themselves up and hurry off as if nothing ever happened."
--Sir Winston Churchill

Heath Ledger's death was such a tragedy, especially considering the cause of his death; accidental overdose of prescription medication. Its so infuriating! We're always talking about asymmetry of knowledge and medication compliance, yet considering the scope of funding in health care, there's very little procured to make the physician-patient interaction more valuable.

We get very little time with our physicians, an average of about 10 minutes to discuss our problems. Considering a physician sees approximately 20 patients or so a day, you, as a patient, have to be succinct and clear in your relay of information and hope the doctor is a good listener. Beyond that, there's little you can change at the point-of-care.

But think of all the things that happen before you even get to see the doctor.

1. You call to make an appointment - insurance registration
   
2. Fill out forms - reason for visit, current medications, medical history
3. Sign some important looking papers - HIPAA, release of medical records
   
4. Get your vitals taken - base health status
   
5. Meet with the nurse - history of present illness (HPI), review of symptoms (ROS)
   

There's potential for breakdown and success on all these counts.

#1. Very little is more hazardous to your health than getting a huge bill from your doctor. Problem: Most likely the breakdown happened when the billing department forgot to call your insurance company and precertify you for services and procedures during your visit. Providing your insurance info is the first part of this whole process!

Solution: No matter how good your doctor's office is, check with the insurance company yourself! Make sure you know your copay and get your deductible information before you go in. After the visit, if you're prescribed a test or medication, check with the insurance company again to see where you should go. Sometimes the pharmacy or imaging center recommended by the doctor's office isn't covered under your insurance (or might not be the cheapest option!).

#2. This is probably the most important of all. Problem: You've written the same thing over and over again going to different doctors, but still you forget what that medication with the long name is called. Or you forget that you finished the course of your antibiotic treatment a few weeks ago. Or you decide that the headaches you've been having every so often are not important for your dentist to know. And did you fax your records from the previous 5 doctors you saw? Do you even remember the second one's name!? The list continues.

Solution: Get all your medical info in one place. Find a doctor that offers a personal health record (PHR) or web portal. Go online to HealthVault, RevolutionHealth, WebMD and fill in the blanks. These sites have put in a lot of work to make it easy for you. If you prefer paper, get a file folder and drop all your info in there. Take a CD, print out your record or take the file folder with you to the doctor's office so you don't forget anything!

#3. Complicated legal forms are a necessary evil. Problem: You don't really care about what you're reading so you sign and date at the bottom and hand them in. The front desk secretary files it away along with your ins. card and photo ID and when you come in the next time, for some reason you have to repeat this process.

Solution: Fill out your medical forms first and hand them to the secretary. Take the time to read what HIPAA is all about and fill out your PCP's name in the medical release form so he/she is notified of the current visit. If you can, check if the doctor's office has an electronic medical record (EMR). This avoids the practice losing papers (because they get scanned in electronically) and saves you time from filling out everything all over again. Also, request a copy of your medical records so you can enter them online or put them in your file folder. A doctor's office has to comply with your request within 30 days (10 if you're from NY)!!

#4. Don't worry about white coat syndrome. You're here to talk about what's wrong and get a medical opinion. On top of that, you came prepared! So relax and let the nice ladies fuss over you.

#5. This is where the nurse will go over everything you wrote down. Problem: There's a game of telephone being played here where the front desk talks to the MA who talks to the NP who talks to the doctor. To their credit, most of it is documented.

Solution: Your job is to be repetitive and stick to your story. Keep in mind the top 3 things you came in to discuss. Don't go on and on about how tired you felt after the Giants tailgate. Nurses usually ask you about pertinent things you might have overlooked like recent minor illnesses, allergies, or over-the-counter medications you're taking. Pay attention and be detailed about your answers.

By the time you get to see the doctor, both of you will have a clear idea of what your record represents and what you're coming in about. After restating the top 3 issues, the repetition can stop. Let the doctor ask the questions, be concise in your answers and ask for further explanation if you don't understand something. By the time you leave, you should have a general understanding of your treatment plan. Ask a nurse or MA for definitions and medical pamphlets after to make sure you have a full understanding . Remember, you're on the clock, so coming in organized prepares everyone for what's important; your health care!

McMe, Myself, and I

"Caveat emptor; 'Let the buyer beware'"
--Laidlaw v. Organ, John Marshall

Super Size Me is a good movie in presentation. A great movie in fact. I haven't eaten McDonald's in a very long time - at least 6 years - and now I definitely know I'm better off for it.

(Weird thing is, I ended up craving some Mickey D's by the end!)

The Last Bite

"Probably the difference between man and the monkeys is that the monkeys are merely bored, while man has boredom plus imagination."
--Lin Yutang

If you like something, do you want more and more of it? Most people generally believe that to be the case. Money, sex, food, friends, free time; in general, the pleasures of life that bring us happiness. But sometimes actually having more of that thing we like doesn't leave us as satisfied as having one less of that thing and wanting one more.

Think about it. Experiencing that mental and emotional desire of meeting a budgetary goal, enjoying a romantic night with your beloved, and craving that last bite of dessert is much more potent than getting as much of those things as we want. You meet a challenge, distance does make the heart grow fonder and too much dessert is bad for you. Its what whets your appetite for more that's enjoyable, not binging on your favorite dish (which just leaves you feeling bloated and sick).

This can be applied. Next time, get one less scoop of ice cream than you want, have one less drink, stop before you're full, spend five minutes less in the shower, get home a little earlier from the bar, watch one less hour of TV. You'll keep craving that activity to the point when you just have to have all of it. And that's one of the greatest feelings in the world.

What's up with the Food Pyramid?

"If you can't easily trace a food back to its source in nature, don't eat it."

--Gregg Avedon

While tracking the evolution of the food pyramid, I became delighted, confused and shocked all at once. What was once holy 15 years ago has now turned completely on its head. A few pictures will help...



What's going on here!? The red meat is now split at the top with white bread, rice and pasta to be used sparingly when before the steak image was lumped in with nuts and fish at 2-3 servings/day and the bread, rice and pasta were at 6-11 servings/day!! Quite the shift don't you think?

Look towards the bottom for daily exercise and plant-based oils as a major component and also the addition of alcohol in moderation. This is in line with what we've all been hearing over the years, but what strikes me is how long it took to get the message out there. I remember my sister and cousins being taught the old pyramid only 4 years ago in middle school and high school. Even if parents have been keeping up with the latest news and research, how are they supposed to explain to their kids that what they're being taught in school is wrong?

If you visit USDA's food pyramid site now, you'll find the most latest version called, MyPyramid. It basically allows you to customize the pyramid based on your age, sex, weight, height and level of physical activity. After inputting all the relevant values, the site provides detailed recommendations and even lets you pick a plan that will lead to a healthier weight (based on your original values). Definitely worth a look. About time they decided to shy away from a one-size-fits-all model.



If you're interested in the progression of changes in the pyramid and want to learn more about why it was so flawed to begin with, check out this page.

EDIT: Here's even more from the Harvard School of Public Health on USDA's flawed methodology in constructing the original food pyramid and how to determine what really is good for you to eat.

A Marketplace for Health Care

"Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to, only so far as it may be necessary for promoting that of the consumer."
--Adam Smith

Carol is a health care marketplace that basically allows you to purchase care packages for what you need. Say you have a sore throat and you're worried it might be something worse. Using Carol's body chart, you click on the throat region, scroll down to sore throat and click on the test, treatment or procedure that most suits your condition. In this case, the options are mononucleosis (mono) symptoms: evaluation & treatment and sore throat: evaluation & management. Clicking on the latter leads to a "compare care packages" page where you can select a vendor based on price and facility.

This is a really innovative way of shopping for health care services. With a "shopping bag" as the checkout cart, bright colors and stylistic fonts, it feels more like you're shopping for clothes on Macy's site than buying an MRI for your knee. The prices are within reason but for now I only see people using this as supplemental insurance (especially for dental care) or if they're lacking insurance for some time. If I were old or poor though, several things would prohibit me from taking advantage of this service; (1) ready access to the internet, (2) tech-savvyness (3) scope of care...oh and the fact that Medicare and Medicaid exist.

What's hard for everyone is terminology. I had no idea what blepharoplasty was until I clicked on it (its eyelid surgery). On the other end of the coin, now I know exactly what it is! Its a great way to learn about health care; the real costs, different insurance models, and how it can be delivered.

Right now we have very little choice. Not anything that's affordable for sure. Carol, while a work in progress, is making headway in providing consumers options to choose from. Making health care more transparent is business everyone benefits from.

EDIT: For a lot more on Carol, check out Scott Shreeve's insightful & detailed commentary here.

Use-Now-Adapt-Later

"I hear and I forget. I see and I believe.
I do and I understand."
-- Confucius

On my hunt for decent (and free) project management software, I discovered the "Use-Now-Adapt-Later" principle. Google promotes this approach through its retrospectiva, a web-based software project management tool it offers as a free d'load. In the end, I went with Access 2007.

But I just the found the principle so intuitive and simple. I mean its nothing more than learning by trial-and-error. You buy a new tv or a computer, what's the first thing you do? Turn it on and start using it! Who really reads the instruction manual right away? I learned most of Excel, Access and even building a blog this way.

You always need the by-the-book folks (they're the ones who write the instruction manuals!), but to really learn and retain something, it has to be contextualized. Yet rarely do we go on an excursion or start a project without a plan. "Think before you act" is overdone. We think too much! Sometimes you just have to jump in and feel it out.

The Doctor-Patient R'ship

How hard is it to find a physician in a new city!? Even if you have access to your insurer's tome (or maybe a small pamphlet) of participating physicians, its tough to know who to pick when you don't have a point of comparison. Even if you ask a neighbor or friend, word-of-mouth is unreliable because there are just too many factors that can make a visit go from great to terrible. Not considering that every patient is literally unique, from genetics to demographics to presenting symptoms. A fact of medicine that's too often overlooked.

Comparing physicians on efficiency though is hard. Dr. Thomas Lee's put together a quick FAQ to explain why. Click below for a better view.

Basically what patients want physicians just aren't ready to give, and for good reason. "Assymetry of information" gets thrown around a lot and its true. The knowledge gap between physicians and patients is enormous, and middleman websites can't make up for 10 years worth of education. Zagat wants to rate physicians on trust, communication, environment and availability. I'm not sure if our loved ones would pass that test. The bridge has to be built on effective communication, where the definition of "effective" is agreed on by both parties. Not third party payers, vendors, clearinghouses, or websites. Its not a round table discussion; its a one-on-one meeting.

Quick! Fill in the blank!

Get rich ____, grab a ____ bite, get in a ____ workout. Everyone's in a rush! All the Zen, the yoga, the meditation fly out the window when there's a deadline to meet, dinner to cook, and people to meet. Like taking prescription pills, we do "healthy" things as necessary, to counteract all the un-healthy things that make up our daily lives. Unfortunately one thing doesn't completely offset the other.

Breathing isn't something that needs to be jotted down in our day planners (remember those!?), whoops, blackberries. As we are forced to focus on the opportunity cost of time more and more regularly, setting priorities make us better decision-makers in every arena, whether it be work, home, or the grocery store.

This great post by Jane Sarasohn-Kahn on slow food and overall slower living kindled the idea for this post. She ends with suggesting a "slow health" movement:

There are certain aspects of modern life that require more than a minute or two of our time. Health is one. Perhaps we should start a Slow Health movement? One contributor to a Slow Health movement would be to pay primary care clinicians to spend more time with patients to listen and to advise. For now, though, let's at least work on ourselves and with those whose lives we touch (who may be consumers or other health stakeholders) to slow down when it comes to analyzing and consulting with health information. Oh, and while I'm thinking about it, cooking and eating as well....

"Code Blue" stat!

Hospital red tape makes casinos and airports better places to have a heart attack and survive! All due to a delay in providing an electic shock with a defribillator. The NYTimes article comments:

In the real world, doctors and nurses do not always run fast enough. Expert guidelines say the shock should be given within two minutes after the heart stops, but the study found that it took longer in 30 percent of the cases.

Certainly disappointing, but hospital guidelines that require a physician's presence at the time of defibrillation are not necessarily to blame. There's a purposeful hierarchy in hospitals that helps faculty and staff work together to make life and death decisions more effectively on the fly. But there's no question that staff can receive better training that can then help them distinguish when a physician's presence is absolutely required.

The article makes a great case for basic defribillator training that could prove true for many other technical functions performed in hospitals.

Dr. Saxon said the automatic defibrillators should be used more, along with the type of heart monitoring now given mostly to cardiac patients. Not everyone needs such monitoring, she said, but it may be in order for those who are very ill with kidney problems, diabetes or pneumonia, even if they have no history of heart problems. Their information would be transmitted to a computer network that would send out an alert if needed. In addition, she said, automatic defibrillators could be installed in every hospital room.

“You can get them for $500 on eBay,” she said. “It wouldn’t even take a nurse. You could train the cafeteria workers if you wanted to.”

So maybe, as in most strict bureacratic organizations, the hierarchy could benefit from being a little more flexible...

Rethinking the school Lunch

I've been thinking about how horrible food is in school cafeterias since I was in middle school. I'd bring food from home and still be tempted to grab a tray full of chicken nuggets, french fries, one of those tiny cups of ice cream and maybe even a discounted soda all for less than $5. I used to wonder why instead of fries and a soda, fresh fruit and milk weren't a viable option. I would later learn that it's simply a cost issue; fruits and veggies are just more expensive than canned or commodity produce subsidized heavily by the gov't. But change is on the horizon.

• Here's what a chef from Berkeley is doing to help.

• Mayor Bloomberg's on a crusade to get whole milk out of New York schools.

• Brian Klepper is promoting doctors to lead the charge on this issue before it gets out of hand.

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Ask Better questions, get more Involved!

Online social networks like Friendster, MySpace and the more recent Facebook have been around for a while now, just about 5 or 6 years. In internet years, that's ancient history! One of the greatest positive externalities to emerge though has been online patient forums like PatientsLikeMe, where people with various diseases have found others to share stories with and talk in general about their personal experiences.

With health care now a 2 trillion dollar industry, everyone wants a piece of the pie. Patients are slowly realizing that they are the centerpiece of the equation and networking sites, medical specialty resources, patient advocacy programs, you name it are all helping them get a stronger foothold by asking the right questions.

Doctors are essential in tearing down the paternalistic structure and increasing the value of patient-physician interactions. With so little time spent with a patient in an exam room, a physician must ask extremely pertinent questions hopefully with foreknowledge of the patient's concerns. Technology is key here; fax, email, best case a web portal to communicate to the doctor the reason for the visit prepares both patient and physician to get past the "sooo, what brings you in today?" phase. Having a mental framework in place allows for treatment options, medication compliance and follow-up to be that much more on target.

There are a lot of people campaigning for this kind of change. NYTimes has a wonderful piece that fleshes out the responsibilities of both patient and doctor even before they meet called "On the Same Wavelength With the Doctor". This is the perspective we need to shake up how things have always been done.

Debating Recession, Building Snakes

Merrill Lynch (but not other banks) think we're already in a recession. They sardonically refute the other banks with,

"To say that the backdrop is 'recession like' is akin to an obstetrician telling a woman that she is 'sort of pregnant'," the report said.

Got it. Most people do think we're headed towards some sort of downturn though. A definition is appropriate here :

The NBER defines a recession as "a significant decline in economic activity spread across the economy, lasting more than a few months".

It bases its assessment on final figures on employment, personal income, industrial production and sales activity in the manufacturing and retail sectors.

On the health care end, we're figuring out ways to avoid using the knife altogether. The i-Snake is a new tool being developed for minimally-invasive heart bypass surgery. I've seen the scars resulting from the old way of doing CABGs, and what they're trying to do here is have "smaller scars, reduced hospital stays and shorter recovery times." Pretty amazing...

Also, if you're having trouble waking up, maybe the SnūzNLūz alarm clock might help. For every push of the snooze button, it sends an amount of money you preset to your most hated charity. Love the common usage suggestions at the bottom of the article,

Are you a butcher? Set your SnūzNLūz to donate to PETA
Are you a republican? Set your SnūzNLūz to donate to the ACLU!

The evolution of a Process

Interface -> Interoperate -> Flow. That's the gist of what makes a system go from local to global. You have to speak the same language - interface - before you can work together as a culture - interoperate - and have a smooth, efficient, cross-functional machine - flow. Each of these terms encompasses hundreds of thousands of people doing different jobs to make it all work in sync.

The financial sector is a step ahead of the rest. Financial Times says a model for direct trading across global borders is projected towards the end of the year, mainly because the interfacing component is coming together quickly:

"SEC staff have been working on a proposal for “mutual recognition” between the SEC and other regulators that would allow the US watchdog to rely on foreign regulators’ standards as US investors trade abroad...

...As part of the new SEC approach, a foreign exchange would be allowed to install a trading facility on the desk of a US broker, provided that the exchages’ home-country regulators’ rules were deemed “comparable” to the SEC’s."

There is a huge demand for this type of service:

"The policy shift, backed by SEC chairman Christopher Cox, has been prompted by the increasing appetite of US investors for foreign securities.

Nearly two-thirds of American investors have holdings in non-US companies, a 30 per cent increase from five years ago."

The odd thing to note here is that while you must interface first before you can interoperate, the demand for interoperability - the desire for culture change - is what leads to interfacing - the desire to speak the same language.

It's what the education and health sectors are lacking. Parents have to want to have the same standards across all public schools, patients have to want to have their records be available everywhere. This isn't as personally sensitive as money, so either we don't care or we're not being informed about the potential of possibility.

At least someone's trying to bridge the GAAP.

Why health care is a Different animal

What an amazing post by Bob Wachter on The Health Care Blog!! It talks about why, compared to other industries, health care is a different animal...with a few similarities of course. Aviation and finance are commonly (and too casually) presumed analogous to health care. Bob really breaks down the thought process of why this isn't the case most of the time but also why this may be a fair analogy some of the time. You need at least a little perspective to work from. Excerpt below.

I continue to find analogies from other industries useful, but we must recognize their limitations. Simple solutions that worked so well in the [fill in the blank] industry often fail in healthcare because our workplace is like a dozen industries rolled into one. For example, a busy hospital and its workers may face these challenges:

• How to move a part (like a pathology specimen) seamlessly down an assembly line, just like Toyota does.
• How to get an important piece of data (like a discharge summary) from place to place, just like FedEx does.
• How to make difficult, weighty decisions (like whether to do open up an abdomen) under conditions of overwhelming uncertainty, just like a field general or a business CEO does.
• How to deal with major and only partly predictable changes in capacity needs (like when the “bus shows up” at 7 pm in the Emergency Department), like McDonalds does at lunchtime.
• How to providing “expectation-surpassing” customer service (so that we ace our Press-Ganey survey), just like the Ritz Carlton or Nordstrom does.
• How to innovate, both with processes and technologies (a consuming interest in an academic medical center like mine), just like Apple does.
• How to teach wildly disparate learners (like the ones on my team when I’m ward attending), just like a high school teacher does (or would do, if her class included freshman, sophomores, juniors and seniors).

Think about it for a second. Can you conjure up another industry that confronts more than two or three of these challenges? I can’t. And not only are all these conditions present simultaneously in most healthcare organizations, there are times when a single doctor or nurse confronts all of them!

Status quo No More

Know someone who doesn't manage their money well? Doesn't pay bills on time, has a lot of credit card debt, maybe loans that are piling up? What happens if you give that person Quicken or some sort of personal finance software? Does that help?

The expected answer is yes. Financial awareness alone has to help in some way. Knowing that you're spending $250/month on Starbucks can be an eye-opener. But over time, the effect of an IT intervention wears off. A lasting effect has to be behavioral, not just technical. Automating poor money management skills won't improve them. Habits have to change. A regular routine must be set. Moderation must be practiced. We all know it, but its tough to find the incentives to get us there.

In some ways, this is the challenge health care is facing with electronic medical records. From major hospital systems to small private practices, conversion from paper to electronic systems is happening at a rapid pace to meet Bush's 2014 deadline for all Americans to have electronic medical records. Everyone is in a state of adoption.

Yet adoption alone, as in the personal finance case, doesn't solve the inherent problem of bad habits and poor management. IT is not the panacea. Rather its the ability to respond and adapt well to change and move yourself or your organization's culture to the next threshold that will keep you competitive. The next best thing will always be around the corner. Its not what will get you there that will matter, but how well you've prepared yourself to be open to a new perspective that will make the difference.

Funding THE PLAN

NYTimes has a great article called, Health Care Expansions Hit Roadblocks, describing the latest major roadblock as cost control for a universal plan. I always thought this was THE greatest roadblock. As the California, Massachusetts, and Pennsylvania plans mature, its slowly becoming clear that unions, insurance companies, politicians all pale in comparison to cost when it comes to providing health insurance for all. The article's flow is choppy, so I chopped it up to make sense out of it. Excerpts are below.

"The downside, and one noted by states with widening budget gaps, is that the program is expected to exceed its first-year budget by at least $150 million. And state officials are struggling to prevent double-digit premium increases next year."

"And though the rate of growth has slowed, the cost of employer-sponsored premiums still rose by 6.1 percent in 2007, more than double the inflation rate, according to the Kaiser Family Foundation."

"[The Plan] would raise money to subsidize policies for low-income residents through what Mr. Schwarzenegger calls shared responsibility — a tax on hospital revenues, a hefty increase in tobacco taxes and assessments on employers who do not contribute to their workers’ health care."

"Illinois’ Democratic governor, Rod R. Blagojevich, got nowhere with his proposals to pay for universal access to insurance by taxing gross business receipts and assessing employers who do not offer coverage to their employees."

“It remains incredibly difficult for states by themselves to get all the uninsured covered,” said Robert Blendon, a Harvard professor of health policy and political analysis. “There just is not a consensus on who should pay.”

Kids being Dangerous

Gever Tulley says there are 5 dangerous things you should let your kids do.

1. Play with fire
2. Own a pocket knife
3. Throw a spear
4. Deconstruct appliances
5. Drive a car

I see what he's getting at, but I remember doing most of these things in technology or gym class. Then again, I also remember the school discontinuing technology because of changing budgetary priorities. So maybe his Tinkering School does have its place.

Check out the full presentation on TED. And because of my thrill for 4a, here's howstuffworks!

The Mitchell Report on Healthcare

Baseball's Mitchell Report has already become infamous for naming names of baseball elite who took or were somehow involved with steroid use. A bit of a formality as most fans are already well aware that baseball players juice up. Home runs fill the seats, and filling the seats means more money for everyone in the MLB.

Not so different from what brings in outpatients to clinics. A little bit of supply induced demand, a dash of fee-for-service, and a (generous) pinch of cost subsidization all generate large sums of revenue for the health care system.

But what is the fundamental issue? Quality. What makes a hit a hit in baseball? Does it still count if Barry Bonds hits the home run or is Edgar Renteria's HR% more real?

Same with quality in health care. What determines quality of care in medicine? What are the metrics? The standards? AHRQ has a lot to say but very little is agreed upon, let alone applied.

The Mitchell Report as I said earlier is a formality, just like all the quality boards and insurer rating systems. They make people aware of the issue, but don't do anything about it. Change happens through culture! Naming names, installing IT systems, ranking doctors are not the solutions, they are the precursors to a solution. They're advertising. But are they really doing a good job of getting our attention?

Get to the Source

"Not everyone in medicine can be constantly making calculations about the value of the information. You'd go crazy. But if you are in a subspecialty field, as you train, you not only need to know what people know, but how they know it. You have to regularly question everything and everyone."

-Dr. James Lock from How Doctors Think by Jerome Groopman

A Trend in the Mass Conscience

Google Alerts basically allows you to search for a given keyword or phrase say, "education", "the war on terror" or "justin timberlake" and sends you alert emails with a comprehensive list of links from news, blogs and the web. Its a really great way to keep track of what you're interested in or curious about.

I've had a google alert for "health care" on since the alert function began earlier this year. I'm used to getting about 5 links for every email alert I get, but recently it has grown exponentially to 10 and sometimes more than 20 links at a time. I assume this means that more people are writing about health care and more people are searching for it as well.

Unsurprising as health care is one of the hottest topics in the upcoming election, yet an unexpected discovery within the google alerts application.

What does Art have to do with Health?

A lot, if you think about it. Asian cultures have been stressing the importance of environment and ambiance on one's health and happiness for ages; feng-shui from China and vastu shastra from India being a few examples. Makes sense that the setup of our room, apartment, or house has a lot of effect on us. So why not the same for patients in hospitals? Get rid of the bland, pasty, grey walls and put in some color!

That's exactly what Women & Children's Hospital in Buffalo is doing. Through grant funding from the Oishei Foundation, the hospital is collaborating with the local Center for the Arts to sponsor

"an intensive training program facilitated by the University of Florida's CAHRE program where local invited visual artists, musicians, poets, dancers, and storytellers will be trained to work with patients, families, and staff in health-care settings as integral members of the healthcare team."

"...studies have shown that integrating the arts into these settings helps to cultivate a healing environment, support the mental and emotional recovery of patients, communicate health and recovery information, and foster positive working conditions for caregivers to improve satisfaction and retention."

The Pebble Project conducts similar health design studies on a much larger scale with multiple hospitals. I got a chance to view first hand some of the benefits when I worked at Weill Cornell Medical College in NYC. In fact, a new building called the Greenberg Center was specifically built with the findings of the project in mind. The goal is

"to create healing environments [that] can impact patient satisfaction, staff satisfaction, nurse retention, medical outcomes, safety, quality, financial performance, and more."

Antibiotics face the Tragedy of the Commons

The evolution of antibiotic resistance is just scary. Through careless prescribing and poor compliance, we've gotten ourselves into a trap referred to as the tragedy of the commons. While each individual faces to gain a large benefit, the cost of that individual benefit is shared across the entire population. Since the individual doesn't see or bear the cost, he/she will continue to do whatever is necessary to reacquire that benefit without public conscience. Hence the tragedy.

Every time an antibiotic is prescribed, the risk of resistance increases. Does this mean we shouldn't be prescribing them? Of course not. But their usage should be governed by special circumstance or how effective they'll be for that individual. Offhandedly prescribing antibiotics for the cold or flu (for which they have no effect because they're viral, not bacterial) has frankly become dangerous. Same with not completing the full regimen prescribed. The FDA provides a brief, informative fact page here.

MRSA or Methicillin-resistant Staphylococcus aureus is a great example of this phenomenon. Methicillin's the antibiotic and S. aureus is the infectious bacteria. This type of staph has become resistant to the antibiotic that killed it and is causing the most havoc in hospitals where bacteria and its killers are in a constant battle. In this case, the bacteria won and now we're recouping for another fight where we've lost the higher ground. This is serious and current!

There's a great sidebar in this USA Today article, "Hospitals marshal resources to wipe out MRSA", that describes how to avoid MRSA. Below are a few excerpts.

"...hospitalizations related to MRSA nearly doubled between 1999 and 2005, from 127,000 to almost 280,000."

"At the University of Texas Medical Branch in Galveston, the main battle strategy against MRSA is what it calls the "search and destroy" method. The hospital screens all adult intensive-care-unit patients each week for MRSA and places those testing positive in isolation."

"Watch before and after an examination. Do doctors wash their hands? If not, ask them to do so. Look around. Is the hospital clean?"

"After any procedure, be persistent about cleanliness. If a catheter is in place, inquire whether it's still needed. Bacteria can enter the device and quickly spread through the body."

The Arbitrageur Next Door

On my flight down to DC a couple weeks ago, I met an arbitrageur. It was in fact the guy sitting next to me, a Canadian driving to Buffalo to take a flight down to North Carolina to buy a truck that he planned to drive all the way back home to...Canada. He was casually indifferent about the whole thing, as if this was a run-of-the-mill endeavor. But really, why go through all this trouble?

At the time, the US$ was worth 92 cents Canadian (CAD). Yet car salesman in Canada hadn't adjusted to the new rates. They were still selling cars at rates about 1.5x the US dollar, which matched the exchange rate almost 4 years ago! A Chevy Silverado that cost around 42,000 CAD was selling for $30,000 in the U.S. My fellow passenger looked to save over $10,000, no matter how you measure it!

That's arbitrage for you; exploiting a price differential between markets. Just because the Canadian auto market is inefficient doesn't mean a consumer needs to lose out. Simpler examples of this concept can be seen at checkouts where all the lines are usually the same length because if one was shorter, someone would leave their spot in the longer line and move to the shorter one. Or in traffic, where all the lanes move at about the same speed, because if one moved faster enough people would switch over until the speeds matched once again.

This is also a great reason not to buy into all the investment advice by so-called "experts" (who are no better at picking stocks than monkeys anyway). If they really knew about the "hot" stock, wouldn't they have told their families and buddies first before informing you!? I'm sure the suggested stock is doing well, but who catches the windfall? The first people to get there. The first to find the shorter line or the faster lane. After that, any major gains are absorbed into the market leaving very little benefit behind.

So my friend in the seat next to me saves $10,000 and enough people will do what he did until Canadian car salesman realize they're losing out, or American car salesman raise their prices.

Pay for Preference

Greyhound's new priority seating option is another example of good economics. If you've ever ridden on Greyhound (especially from NYC!) you know how bad the lines can get and as a result how irritated people can get. In some senses, I think they're replacing poor management with a cost-benefit exchange, but that doesn't change the fact that it makes sense.

Movie theaters in major urban centers do the same thing by allowing movie-goers to reserve seats in prime locations of the theater, sometimes even with a snack/beverage service. Its been this way on Broadway and stadiums and airlines all along, so why not?

Repugnancy costs originating from cultural mores. That's the answer. But is it a good one?

As the Wii is to Canada, the PS3 is to America

The demand for Nintendo's Wii has not diminished since its revolutionary arrival last Thanksgiving. Yet Nintendo is still hesitant to increase its supply or raise the price of the Wii to reach some form of market equilibrium. This has led to long waiting lines outside toy and gaming stores, sometimes at odd times like Sunday at 8 am to weed out the casual gamer.

For some reason the Wii is being rationed, similar to how health care is rationed in Canada or the UK. There is ample demand in Canada, yet few monetary or policy incentives to increase supply. With limited (funding for) clinics, hospitals and new technologies, doctors have little motivation to open up shop and patients sometimes have to wait 3-6 months for a surgery or visit. Its one of the best representations of the saying, "there's no such thing as a free lunch". Government-regulated single-payer health care may seem "free" on the surface. But you end up paying for it in time and taxes.

Now take the PS3. Sony's debut of the PS3 occurred at the same time as the Wii, but (due to marginal cost) it was priced 3x higher (originally $799, now $399). No waiting lines here! In this case, the exorbitant price left only the hardcore gamers interested and not until the cost of producing such a high-end system went down did consumers see a reduction in price.

In this way the PS3 is akin to the American health care market. A quality product rationed by price. The high-end users (the sickest patients) are most indifferent to price and will purchase care at any cost simply because they need it (its the job of the insurers to reduce the financial burden in such a time of need). Other medium to low-end consumers can make a personal decision based on price and predicted value.

This simple analogy gives a brief glimpse of why international health care markets differ and how single-payer systems ration care. The PS3-America analogy wouldn't be complete without mentioning third-party payers though. Health insurance in the U.S. doesn't function like car or life insurance. Rather than providing catastrophic coverage and raising premiums based on client risk, health insurance subsidizes cost of care at the episodic level. This breeds overuse. It would be similar to someone giving you the PS3 at half the price when it just came out!

Pricing matters, whether its through premiums or taxes. When presidential candidates hint at universal health care, they should provide more than just hints about how much it will take out of your paycheck each time to support the high-end system we are fortunate to have in the U.S.

EDIT (12/14/07): PS3 sales have skyrocketed by 300% since the price changes in mid-October. Here's the article.