Friday, August 31, 2012

Rock Health, Enterpreneurs, Doctors and Witchcraft?

I recently viewed health care through the lenses of a technology entrepreneur by attending the Health Innovation Summit hosted by Rock Health in San Francisco. As a practicing primary care doctor, I was inspired to hear from Andy Grove, former CEO of Intel, listen to Thomas Goetz, executive editor of Wired magazine, and Dr. Tom Lee, founder of One Medical Group as well as ePocrates.

Not surprising, the most fascinating person, was the keynote speaker,
“Health care is like witchcraft and just based on tradition.”

Entrepreneurs need to develop technology that would stop doctors from practicing like “voodoo doctors” and be more like scientists.

Health care must be more data driven and about wellness, not sick care.

Eighty percent of doctors could be replaced by machines.

Khosla assured the audience that being part of the health care system was a burden and disadvantage.  To disrupt health care, entrepreneurs do not need to be part of the system or status quo. He cited the example of CEO Jack Dorsey of Square (a wireless payment system allowing anyone to accept credit cards rather than setup a more costly corporate account with Visa / MasterCard) who reflected in a Wired magazine article that the ability to disrupt the electronic payment system which had stymied others for years was because of the 250 employees at Square, only 5 ever worked in that industry.
Khosla believed that patients would be better off getting diagnosed by a machine than by doctors. Creating such a system was a simple problem to solve. Google’s development of a driverless smart car was “two orders of magnitude more complex” than providing the right diagnosis. A good machine learning system not only would be cheaper, more accurate and objective, but also effectively replace 80 percent of doctors simply by being better than the average doctor. To do so, the level of machine expertise would need to be in the 80th percentile of doctors' expertise.

Is it possible technology entrepreneurs can disrupt health care? He challenged any doctor in the room to counter his points.


Was it because everyone agreed? Were the doctors in the room simply stunned? Was there a doctor in the house? And where did he get that 80 percent statistic?

Was Kholsa serious that technology could make health care better by utilizing large data sets and computational power to clinch better and more precise diagnoses?  Was he simply being provocative to hear other points of view to learn even more? Like many others in the conference, he believes that giving consumers more opportunities, access, and choice to information about themselves and their bodies would empower them to do the right thing. He held up an EKG attachment to the iPhone which was just one of many consumer directed products in the pipeline his company has invested in.

Kholsa is a very smart and successful entrepreneur. Does innovation mean the two guys in a garage who come up with a radical idea or is it possible that innovation is having people with different experiences and point of view looking at the same problem as best selling author Malcolm Gladwell noted in his New Yorker piece Creation Myth -  Xerox PARC, Apple, and the Truth About Innovation? Surely to make health care better, technology entrepreneurs must engage with doctors. All the speakers before and after Kholsa spoke about the incredible value and insight different stakeholders to bring to the table.  The most vocal? The doctor entrepreneurs and those who worked with doctors to bring their ideas to market.

Kholsa's criticism of the health care system is completely valid. Can we do better in being more reliable, consistent, and creating a system process and design that is comparable to highly reliable organizations and industries? Of course. Can we be more systematic and doing the right things every patient every time on areas where the science is known to level of the molecule? Yes. Care must be incredibly simple to access, extremely convenient and intensely personal.

It isn't that we don't have smart people. Compared to a century ago more illness are understood, specific medications and treatment protocols can be designed. But we haven't solved it all. When we thought we knew it all, we were shown how little we truly knew. Thirty years ago, doctors predicted the demise of infectious diseases as a specialty, another footnote in medical texts as more powerful antibiotics and vaccines were available. Enter AIDS, the swine flu, and many super-bugs which have humbled our profession. Ask accomplished physician and writer Dr. Abraham Verghese about his experiences.  Dr. Verghese is rightly worried, as many others are, that even doctors are being too focused on the iPatient and not on the real patient as he writes in his New York Times op-ed Treat the Patient, Not the CT Scan. Is this what we want our health care system to look like?

Health and medical care is an incredible intersection of technology, science, emotions, and human imperfections in both providing care and comfort. As conference speaker Dr. Aenor Sawyer, an orthopedic surgeon from UCSF noted, we need to figure out how to have our different cultures of doctors, gamers, designers, and technologists interact. Fixing health care is more than simply "we know the problem and we know the solution". She reflected that the level of dedication, perseverance, and a willingness to make impact among the different groups demonstrates more similarities than differences.

I know health care can't simply be solved by smart people in Silicon Valley alone.  To solve health care we need everyone to collaborate. As Harvard Business School professor Amy Edmondson noted in her book Teaming

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."
Perhaps Kholsa's call to action was simply an entrepreneurial mindset, but simply ignoring those who have chosen a field to improve and safe lives and who meet humanity everyday on the front-lines is problematic and dangerous. There are some things that may never be codified or driven into algorthims. Call it a doctor's experience, intuition, and therapeutic touch and listening. If start-ups can clear the obstacles and restore the timeless doctor-patient relationship and human connection, then perhaps the future of health care is bright after all.

Tuesday, August 21, 2012

Five Vital Skills to be The Thrifty Patient

From my upcoming book - The Thrifty Patient - Vital Insider Tips For Saving Money And Staying Healthy

Chapter 2 - The Thrifty Patient

Five Vital Skills to Staying Healthy and Saving Money

Throughout the book, we’ve covered various important aspects of getting the right care. It boils down to five separate but important areas you should be knowledgeable about: the doctor’s office visit, prescription medications, preventive screening tests and interventions, selecting the right doctors, and using the Internet. Each is also important to help save money. For example, learning how to communicate with doctors clearly about your concerns and needs as well as providing the doctor the information he needs can decrease the likelihood of unnecessary testing and medications. When seeing a doctor, the goal is to solve the problem you are having. It isn’t to get all of the imaging tests, lab work, or prescription medications available. When focused on the right goal, you get the right care and save money.

Sometimes, paradoxically, this may mean spending money to see the doctor to pick his brain and get his expertise. You may be tempted to ask for blood work or a MRI first and skip the office visit. Talking to a doctor seems so old-fashioned and out of date. Yet, as we will review, lab work and imaging tests are simply tools to help doctors. By themselves, without a good patient history, the test results have little meaning.

If your doctor recommends prescription medication, then there are ways to ensure that the medications you receive are effective and affordable. Many prescription medications are simply me-too or copycat drugs. Pharmaceutical companies market and promote these medications as aggressively as beer and soda. Don’t be fooled. When a medical condition is common, such as heartburn, seasonal allergies, high cholesterol, high blood pressure, and diabetes, save money by avoiding the latest advertised medication. There are often plenty of excellent and less expensive alternatives.

Focusing on prevention is extremely important. 

Getting screened for cancer and requesting vaccinations can keep you healthy. 

It isn’t particularly sexy, trendy, or even fun depending on these tests, but they can save your life. Periodically check out what the latest guidelines are, as the recommendations can change with continued medical research.

Identifying which doctor to go to is also important to getting the right care. 

It is extremely rare that any one doctor is the “best.” Don’t worry about finding the best, but rather focus on finding doctors who provide excellent quality care and who also listen to you. How do you determine if a doctor is good? How do you find one? Who is on your medical team? Should you always have a primary care doctor? If you need a specialist, how do you choose?

We also will review the use of the Internet and social media as a way to keep you informed. 

The ease of accessing information can both be a blessing and a curse. Used correctly, information from the Internet, whether from trusted health care organizations, patient or doctor blogs, or tweets, can improve decision making. It may help you determine if a symptom requires medical attention or can be safely treated and managed at home. Yet the access to this information can be equally as problematic.

The Internet, much like the lab tests and imaging studies doctors use, is still a tool. Like any tool, it can be helpful or harmful depending on how a person uses it. A simple rule of thumb—if an answer or solution sounds too good to be true, it often is.

Increasingly, you are being asked to pay more for medical care and be more responsible in making medical decisions. Knowledge is power. It isn’t that hard. Let me show you how.

Five simple skills can make you a thrifty patient who is staying healthy and saving money.

Finally, just a brief primer on what you should do outside of where I work regularly, the medical system. For most of us, life is not filled with doctor visits. That’s a good thing. Sometimes you or a loved one does, however, need our help. This is the first step to getting you the skills you need to stay healthy and choose wisely.

Let’s get started.

Thursday, August 9, 2012

Update on The Thrifty Patient - Vital Insider Tips For Saving Money And Staying Healthy

New book is finally taking shape. A revised and streamlined version of my previous work with new content is nearly completed and will be available soon on Amazon and Kindle.

Here is a sneak peak of the first chapter!


Introduction –

Why This Book Matters To You

After you finish this book, you will know what I know when it comes to medical care. I believe it can be boiled down into these short but important phrases.
  • Newer isn’t necessarily better.
  • More isn’t necessarily better.
  • Common sense may not apply.
  • Staying healthy and well means sometimes seeking medical care.
  • You need to be informed and educated to get the best care.
Or I could burden you with statistics from the health care system
which you probably already know.
  • Twenty-three seconds.
  • Fifteen minutes.
  • Forty percent.
  • Medical costs.
  • Increasing dissatisfaction.
  • Worst among industrialized countries.
These are the questions to the previous answers.

  • Twenty-three seconds: How much time do you have before your doctor interrupts you?
  • Fifteen minutes: What is the average face-to-face time at a doctor’s office visit?
  • Forty percent: What is the misdiagnosis rate based on autopsy?
  • Medical costs: What is the leading cause of personal bankruptcy? Many had health insurance.
  • Increasing dissatisfaction: How does the public feel about the American health care system?
  • Worst among industrialized countries: How does the United States rank in terms of health care quality for prevention and treatment?
Staying healthy and well means sometimes seeking medical care. 
I could tell you that too many Americans die every year unnecessarily and too soon due to missed opportunities. Healthy patients forget to get screened for colon cancer or breast cancer. Heart attacks and strokes that could have been prevented occur. Grandfathers and grandmothers aren’t around to attend holidays, graduations, or spend time with their grandchildren. Parents leave their children alone because their cancer was caught too late. No one is the wiser to this.

Newer isn’t necessarily better. More isn’t necessarily better.
You may have noticed that increasingly doctors rush through office appointments and don’t listen. Too often blood work is done, medications prescribed, and x-rays ordered, and despite all of the additional treatments patients don’t feel healthier. Television, radio, magazines, and the Internet inundate you with the latest prescription medications or therapy promising you better health. The news warns you to check with your doctor about the latest therapy with quick, thirty-second sound bites. You are fearful that you might be missing something important that could save your life.

Common sense may not apply.
Increasingly more parents are not having their children immunized against preventable illnesses such as measles and pertussis (whooping cough). Now news reports note more cases. Some children die. Many have lost faith and look for alternative and more “natural” therapies. Doctors who are supposed to help guide you and distinguish truth from fiction are just too busy, so more people are relying on family, friends, and the Internet for medical advice.

You need to be informed and educated to get the best care.
To add even more stress, health insurance is becoming too expensive. Small and large companies are trying to control costs by offering health insurance with health savings accounts (HSAs). These plans have lower monthly premiums with high deductibles. Since 2004, these plans have become more common. Many patients are now asked to choose when to seek care and when to safely skip care based not only on their health needs but on their ability to pay, even as research consistently shows that they don’t want the financial responsibility to do so.

There is good news.
Despite all of these challenges, there is good news. You aren’t alone. When I took the Hippocratic oath to do no harm and help patients to the best of my ability, I didn’t realize that pledge included writing a book. I’ve always wanted to be a doctor. Never a writer. I hated English. I only took the class because I had to, not because I wanted to. 

Despite that, I am compelled to write because of what I know is occurring with alarming frequency in our country. Americans are skipping needed and recommended care that could save their lives and allow them to live to their fullest. Patients are more distracted, as life is more complicated and busier than ever. Households have both parents working, sometimes two jobs, just to make ends meet. They easily would make the right choice if someone would be willing to explain things in a simple, understandable manner. They would prefer a health care system that was so incredibly simple to use, convenient, and personalized that it would anticipate their needs so they could get the right care and get back to living life.

Instead, our health care system offers patients higher co-pays, deductibles, and out-of-pocket medical expenses. It shifts the burden of making the right choices to people who frankly are just getting by. It asks people to fend for themselves at a time when they need us, doctors, the most.

How do I know? Two things occurred that changed my life.

Wednesday, August 1, 2012

Doctors, Patients, or Insurers - Who Will Shape Health Care?

Recently New Yorker staff writers and best-selling authors Malcolm Gladwell and Atul Gawande addressed the question of whether the problem in health care is that patients are too reliant on doctors and don't have the ability to make decisions. In reading between the lines, is that the reason health care is not affordable and care not commoditized or consumer driven like other industries?

At a conference for America's Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too "high", that individuals willingly to defer the responsibility to someone else? Gladwell hints that might be a possibility:
"A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else," said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse....

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. "In healthcare we don't have the same stomach for that period of transition. That's striking to me."
The disruptive innovation that Gladwell is hoping for has yet to affect healthcare. It is possible that as more Silicon Valley start-ups focus on making medical care more convenient, worry-free, hassle-free, more personalized, and more accessible that the majority of individuals won't adopt them because doctors don't approve. The shift to a "temporary deficit in performance" may not be as acceptable even if less expensive and more convenient. As Gladwell notes in the case of dialysis, despite being around for over seven decades, patients in general still don't self-administer treatment, which would be less expensive, but rather continue to go to facilities which are overseen by doctors.

His colleague, Dr. Atul Gawande, countered that other industries, like "teaching, firefighting, and police work" still have intermediaries that do the work on behalf of the individuals. Gawande believes that the real issue is that the care we provide as doctors isn't integrated. We focus on optimizing each part of the health care system without looking across the entire experience of care. Extending this analogy to building the best car and using the best manufacturer for each part, Gawande notes:
building a car with Porsche brakes, a Ferrari engine, a BMW chassis, and a Volvo body. "Put it all together and what you have is an expensive pile of junk that doesn't go anywhere because the pieces don't work together,"
No where was the need for doctors to lead change and think about the entire experience for the patient more clear than a recent New York times piece by health reporter Tara Parker-Pope, titled "Too Much Medical Care". She chronicled her experience as an educated patient and parent of a daughter who suffered an ankle injury at camp. She started first with:
Pediatrician. Initial visit. 
One month later, still not better so she takes daughter to Sports Medicine specialist. MRI ordered.
Referral to Pediatric Orthopedic Surgeon. Another MRI. Blood work.

Slightly abnormal blood work.
Referral to eye specialist.
Referral to pediatric rheumatologist. More blood work. Another (3rd) MRI. Xray of hands.
Five months after original injury, daughter notes that her ankle still hurts. 
Finally, Parker-Pope takes back control. She consults with the sports medicine specialist who reviews the case with the pediatrician. The focus in back on the patient and pain relief. Soon, the daughter is back to resuming her activity.

In retrospect, what is most surprising is how long the entire process went and still the daughter's problem hadn't been solved. Three MRIs for an ankle injury. Four specialists. Three MRIs. Many blood vials drawn. Xray of the hands, though the ankle was the injured joint. It's not that Parker-Pope is naive or uneducated. She is a health reporter for the New York Times and has talked to many doctors and written many stories. The fact that she and her daughter were caught up in the health care system illustrates the challenges facing the public.

Solving the health care crisis will require both points of view offered by Gladwell and Gawande. We need both patient engagement as well as a more coordinated integrated health care system. It is however increasingly clear, particularly based on the New York Times piece, that empowered patients alone won't be able to bend the cost curve. Despite the easy availability of information via the internet and self-diagnosis, there is value to the "expert" in determining the right course of action. As both Gladwell and Gawande note in their previous works there is a need for 10,000 hours of deliberate practice to become expert and that even the experts need coaching for continuous improvement, respectively.

The real problem is whether the "experts" are willing to make the judgement calls that our training provides? When to refer? When not to refer? When to get the MRI? When not to get the MRI? When to prescribe antibiotics? When to hold ground and sympathize when it is a virus? When to comfort, empathize, and heal when it means stopping chemotherapy when treatment is futile? When to do surgery? When to hold off? Are we willing to have others observe us in action so we can be even better? If not, why not?

For health care to be better, doctors must lead the change. No one else can. Insurers and employers have exhausted strategies to make patients more accountable.  Increasing deductibles and co-pays indefinitely won't work. Despite the unprecedented access to information, empowered patients and other patient advocates will never be able to fully close the knowledge gap. That difference in knowledge, as Gladwell points out in his book, Blink, is what allows an expert to distinguish between an authentic piece of artwork and a very good looking fake.

It is also the difference between stopping a number of unnecessary referrals and the cascade effect of subsequent imaging, blood work, and appointments and instead focusing on the patient.

Who will shape health care? Doctors, Patients, and Insurers and in that order.

Or entrepreneurs who partner with doctors to solve our challenges so we can go back to focusing on healing patients.


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