Tag Archives: bewell

SmartWatch Technology Reliably Detects Afib

The quantified self movement strikes again!

CREDIT: Cleveland Clinic Article on Detection of Afib via SmartWatch

Smartwatch Technology Reliably Detects Afib Prior to Cardioversion
Study suggests a role for KardiaBand when paired with physician review

A newly FDA-approved smartwatch accessory can record heart rhythm and successfully differentiate atrial fibrillation (AF) from normal sinus rhythm (SR) through an automated algorithm, according to a Cleveland Clinic investigation. The study, which will be presented March 11 at the American College of Cardiology’s 67th Scientific Session, also showed that the accuracy of interpretation gets even better when the accessory is supported by physician review.
The findings suggest that the wearable technology, known as KardiaBand™, can help screen patients before presentation for elective cardioversion to avoid unnecessary procedures, among other potential uses.
KardiaBand, which consists of a software app for an Apple Watch® and a sensor band that replaces one of the watch’s straps, provides a 30-second recording of an ECG rhythm strip when the wearer places a thumb on the sensor band. The app contains an algorithm for automated detection of AF.
“Our objective was to determine how accurately KardiaBand and its algorithm can differentiate AF from sinus rhythm compared with physician-interpreted 12-lead ECGs,” says senior author Khaldoun Tarakji, MD, MPH, a Cleveland Clinic electrophysiologist. In November 2017, the device became the first smartwatch healthcare accessory to be approved by the FDA, “but we wanted to test it ourselves to determine how well it would perform in clinical practice,” Dr. Tarakji explains.
Study essentials
To that end, he and Cleveland Clinic colleagues prospectively enrolled 100 consecutive patients (mean age, 68 ± 11 years) with chronic AF who were scheduled to undergo cardioversion. Upon presenting for the cardioversion procedure, all patients were given a KardiaBand-equipped smartwatch and trained in its use, after which they underwent traditional ECG assessment and a 30-second KardiaBand recording. If cardioversion was still indicated, they underwent ECG and KardiaBand testing after the procedure. KardiaBand recordings were then compared with the physician-reviewed ECGs and also reviewed by two blinded electrophysiologists, with these readings compared to ECG interpretations.
Eight patients did not undergo cardioversion because they presented in SR; these patients were excluded. Among the remaining patients, a total of 169 pairs of ECG and KardiaBand recordings were available for comparison (each patient had two before and two after cardioversion).
Key findings
• Of the 169 pre-cardioversion KardiaBand recordings, 57 fell out as “unclassified,” meaning that the KardiaBand algorithm did not draw a conclusion of either AF or SR.
• Among the remaining 112 pairs of recordings, the reviewing electrophysiologists determined that the KardiaBand algorithm correctly detected AF with 93 percent sensitivity and 84 percent specificity compared with ECG.
• When the blinded reviewers bypassed the automated algorithm and interpreted each patient’s KardiaBand strips against his or her ECG, sensitivity rose to 99 percent and specificity was 83 percent. Further, in the 57 unclassified cases, the reviewers were able to use the strips to correctly diagnose AF versus SR with 100 percent sensitivity and 80 percent specificity.
“This study shows that KardiaBand provides excellent sensitivity and good specificity in identifying AF,” says Dr. Tarakji. “The numbers improve further with physician overview of these recordings, indicating that even unclassified KardiaBand strip recordings could be of value to reading physicians.”
Smart devices demand smart use
KardiaBand carries the benefit of enabling patients to record their rhythm at any time, as opposed to only when they are wearing a Holter monitor or at a physician’s office. “We can catch intermittent episodes when they happen, and we’re not limited to a specific duration of monitoring time,” Dr. Tarakji says. He adds that wearable devices like this can also reduce time spent responding to false alarms if a recording taken at the same time shows normal rhythm.
Yet many questions remain about how KardiaBand and similar products may ultimately be used in practice. Dr. Tarakji cites a few examples:
• Which patients are best suited to this technology? For many patients dealing with AF, KardiaBand can provide reassurance when they need it. But for others, having constant access to their ECG data may lead them to check their rhythm obsessively, raising anxiety. “In general, however, patients value the instant feedback they get,” Dr. Tarakji observes.
• Do physicians have the IT infrastructure in place to make these devices part of their practice? Wearable devices can mean a flood of event reports to clinicians’ email boxes. At Cleveland Clinic, information from patients’ KardiaBands bypasses the email system and feeds into a cloud-computing platform that physicians can access anytime.
• How should clinicians respond to short episodes, particularly in asymptomatic patients? “We currently have a gap in our clinical knowledge about whether brief, random episodes that are asymptomatic warrant anticoagulation or not,” Dr. Tarakji explains, adding that ongoing studies are trying to address this important question.
“Future studies will focus on how we can use these smart devices intelligently to make sure they’re improving quality of care rather than just producing noise for physicians,” he observes.
A parallel goal, he says, is to ensure that the devices provide value by making care delivery more efficient. Noting that patients currently need to pay for KardiaBand out of pocket, Dr. Tarakji says that “developing a richer body of research evidence is the best way we can demonstrate cost-effectiveness to healthcare payers.”
Tech like this can’t be ignored
Indeed, KardiaBand could prove cost-effective by allowing patients who are in SR to avoid needless trips for elective procedures, such as in the case of the eight patients in the study who were found to be in SR when they presented for cardioversion and did not require the procedure. Other potential uses of KardiaBand for the longitudinal management of AF patients could well prove cost-effective too.
Regardless of how quickly such cost-effectiveness evidence may come, Dr. Tarakji says clinicians cannot be passive in the face of technologies like KardiaBand. “Patients will come to us with new products, and we can’t turn away,” he observes. “We need to test these products and find ways of responding to the information they deliver in a way that improves patient outcomes, all while remaining mindful of both patient and physician satisfaction.”
The researchers report that KardiaBand’s manufacturer, AliveCor, provided smartwatches for the study but was not involved in the study’s design, implementation, data analysis or interpretation.

Well-Being – Real Time Revisited

NOTE: This post revisits a post titled “Well-Being Real Time”. The original post was May, 2014, and can be found at: http://johncreid.com/2014/05/well-being-real-time/.

Well-Being – Real Time Revisited

Well-being is arguably the central mega-trend of the 21st century. As we look to the future, we have an obligation to “unpack” this dense concept, and find its essential component parts.

We describe these components here as “ACE” – ACT, CARE, and EAT. The wish we have for ourselves and for others is to be well. “Be Well” is our salutation and our call to actions.

How far out are we looking?

The future is now. ACE is here – together with real time measuring and monitoring. ACE is our pathway to greater and greater levels of personal well-being.

ACE measuring and monitoring will be supported by all elements of the quantified self movement. FitBit, Apple Watch, and so many other new monitoring devices will allow us to to bring personal well-being into a real-time modality.

ACE represents three pillars, each deceptively simple:

A – ACT: ACT is short for activity. The call to action is “stay active”. Well-being activity has physical activity at its center, but the pillar also embraces social activity, and activities of the mind. Staying active is a critical element of being well.
C – CARE: CARE is short for well-being care. The call to action is “care for yourself” and “care for others.”Well-being care of course has health care at its center, but there is so much more. e.g. genomics, massage, essential oils, acupuncture, etc. “Caring for myself” and “Caring for others” are elements of this pillar. “Preventive care” regular check-ups, colonoscopies after age 50, mammograms, pre-natal care for expecting mothers, etc.
E – EAT: EAT is short for eating and drinking. The call to action is “Eat well.” Well-being eating is the exploration of how what we eat and drink contributes to our well-being.

As simple as these pillars appear, each is complex: deep enough for a life-time of focus. Each represents bodies of research, skills, capabilities, and areas of professional endeavor. All together, these pillars represent pathway that each of us will follow as we attain greater and greater levels of personal well-being.

Discussion:

ACT

A – ACT (walking, running, calories burned etc)

Staying active is a critical element of being well. Well-being activity has physical activity at its center: sports, walking, lifting, climbing, yoga, and all of the other activities that light up a FitBit. The pillar also embraces activity of other kinds, e.g. social activity, and activities of the mind.

CARE

Well-being care is all about promoting health. Of course, it has health care at its center, but there is so much more. e.g. mental health, addictive behaviors, massage, genomics, essential oils, acupuncture, etc.

“Caring for myself” and “Caring for others” are elements of this pillar. “Preventive care”, eldercare and aging, palliative care are included, but so are regular check-ups, colonoscopies after age 50, mammograms, pre-natal care for expecting mothers, etc.

The ability to routinely monitor vital signs at home or at the office will be a part of this pillar. Lab work – including saliva, blood, and stool samples, will be more real time, more regular and less expensive. These trends will be one of the keys to progress in the care pillar. On the innovation side of this pillar will be many technologies, but breakthroughs in genomics will certainly be high on the list. Telemedicine is another innovation that will alter access to well-being care.

Predictive modeling will be more relevant than never. Am I headed for pre-diabetes? If so, what evidence shows me a path to avoid that condition?

CARE-MMEDS (what MEDS I take, what compliance I have, etc)

CARE-RResting Metabolic Rate (calories burned at rest)

CARE-VVITALS (pulse, BP, etc)

CARE-LLABS (blood testing, etc)

CARE-SSleep (duration, deep sleep, etc)

EAT

EAT is short for eating and drinking. The call to action is “Eat well.”

Well-being eating is the exploration of how what we eat and drink contributes to our well-being. Naturally, there is a social element, where eating and drinking together makes the experience more fulfilling. There is a physiological element, having to do with ingestion, osmosis, calories, glucose and glycogen, enzymes, etc. There is a psychological element, related to the feelings of satiety, or hunger, or thirst, and their related cravings. There is a sensory element, where sweet and sour contrasts, aromas, and their related metaphorical associations, play a part.

Eating delicious food and drink with friends is certainly a component. But achieving a balanced diet, with moderation as a central tenant,

On the one hand, this pillar is ancient. For thousands of years, elders have taught daughters and sons how to cook well. and cooking techniques have evolved

On the other hand, this pillar is ripe for innovation. The new breakthrough science related to the micro-biome is a part.

EATS (what I eat and drink, especially calories)

Implications

Monitoring all components of ACE (MEDS, Activity, Resting Metabolism,VITALS, EATS, LABS, Sleep) is now going to accelerate at an exponential rate.

There will be three settings where ACE monitoring will accelerate:

Employees in Workplaces: Employers will offer employees routine monitoring as part of employee benefits and/or health insurance.
Residents in Communities: Communities will offer residents routine monitoring as one of their amenities. Wellbeing facilities and programs will become as important as golf courses and swimming pools. Look for HOA’s,Condo and Coop associations, and subdivision developers to increasingly view MARVELS as critical to “place-making”.
Clients of service-providers: Hotels, spas, assisted-living centers, nursing homes, and many others will increasingly offer MARVELS monitoring as one of their base services.

The Privacy Imperative will be the critical success factor for all of these pushes into the future. It is foundational.

Without it, there will be no progress.

With it, personalized, real-time care will flourish. Each individual will be able to opt-in to his care-coaching community (and to opt-out whenever they choose), and get the extraordinary benefits that such a community can provide.

Want to talk to your well-being coach? FaceTime them, and they – with your permission – will help you sort out what’s going on with you.

Feel like you might need a check-in with a doctor? Send them an email – with your ACE history embedded in it, or get them on the phone or FaceTime, and see if they need you to come in.

The future is now.

BEWELL Centers will be everywhere. Look for:

DWELL CENTERS (part of BEWELL Centers) – for community ACE measuring and monitoring support. Target population is neighbors in the community.

Employee BEWELL CENTERS (part of BEWELL Centers) – for employees in workplaces ACE measuring and monitoring support. Target population is employees in the workplace.

CLIENT BEWELL CENTERS (Part of BEWELL Centers – for service-providers ACE measuring and monitoring support.Target population is clients of the service provider.
(Walgreens and CVS are already moving aggressively in this direction>

References:
The Privacy Imperative
LABS revolution
LABS By Disease
Quantified Self Movement

Amazon, BH, JPMorgan

With 1.2 million employees, Amazon, Berkshire Hathaway, and JP Morgan have decided to venture together into health care for their employees.

Following in the grand tradition of Henry Ford, who set up Henry Ford Hospital in Detroit, these three giants are stepping in too.

They have no illusions about how difficult it will be. But with premiums rising 19% per year, its clear that Congress is doing nothing, and someone has to do something.

“Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Mr. Combs; and Beth Galetti, a senior vice president at Amazon.”

The article points out that there are others working on this.

“Robert Andrews, chief executive of the Healthcare Transformation Alliance, a group of 46 companies, including Coca-Cola and American Express, that have banded together to lower health care costs.”

“Walmart contracted with groups like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need organ transplants and heart and spine care.”

“Caterpillar, the construction equipment manufacturer, sets its own rules for drug coverage, which it has said saves it millions of dollars per year, even though it still uses a pharmacy benefit manager to process its claims.”

Suzanne Delbanco, the executive director for the Catalyst for Payment Reform, a nonprofit group that mainly represents employers”

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CREDIT: https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan-health-care.html?smid=nytcore-ipad-share&smprod=nytcore-ipad

TECHNOLOGY
Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care

By NICK WINGFIELD, KATIE THOMAS and REED ABELSON
JAN. 30, 2018
SEATTLE — Three corporate behemoths — Amazon, Berkshire Hathaway and JPMorgan Chase — announced on Tuesday that they would form an independent health care company for their employees in the United States.

The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment. It also caused further turmoil in an industry reeling from attempts by new players to attack a notoriously inefficient, intractable web of doctors, hospitals, insurers and pharmaceutical companies.
It was unclear how extensively the three partners would overhaul their employees’ existing health coverage — whether they would simply help workers find a local doctor, steer employees to online medical advice or use their muscle to negotiate lower prices for drugs and procedures. While the alliance will apply only to their employees, these corporations are so closely watched that whatever successes they have could become models for other businesses.

Major employers, from Walmart to Caterpillar, have tried for years to tackle the high costs and complexity of health care, and have grown increasingly frustrated as Congress has deadlocked over the issue, leaving many of the thorniest issues to private industry. About 151 million Americans get their health insurance from an employer.
(Why will health care be so difficult for these companies to untangle? Analysis from The Upshot.)
But Tuesday’s announcement landed like a thunderclap — sending stocks for insurers and other major health companies tumbling. Shares of health care companies like UnitedHealth Group and Anthem plunged on Tuesday, dragging down the broader stock market.

That weakness reflects the strength of the new entrants. The partnership brings together Amazon, the online retail giant known for disrupting major industries; Berkshire Hathaway, the holding company led by the billionaire investor Warren E. Buffett; and JPMorgan Chase, the largest bank in the United States by assets.

They are moving into an industry where the lines between traditionally distinct areas, such as pharmacies, insurers and providers, are increasingly blurry. CVS Health’s deal last month to buy the health insurer Aetna for about $69 billion is just one example of the changes underway. Separately, Amazon’s potential entry into the pharmacy business continues to rattle major drug companies and distributors.
(Here’s a look at how the even the threat of Amazon’s entry into an industry can rattle stocks.)

The companies said the initiative, which is in its early stages, would be “free from profit-making incentives and constraints,” but did not specify whether that meant they would create a nonprofit organization. The tax implications were also unclear because so few details were released.
Jamie Dimon, the chief executive of JPMorgan Chase, said in a statement that the effort could eventually be expanded to benefit all Americans.

“The health care system is complex, and we enter into this challenge open-eyed about the degree of difficulty,” Jeff Bezos, Amazon’s founder and chief executive, said in a statement. “Hard as it might be, reducing health care’s burden on the economy while improving outcomes for employees and their families would be worth the effort.”

The announcement touched off a wave of speculation about what the new company might do, especially given Amazon’s extensive reach into the daily lives of Americans — from where they buy their paper towels to what they watch on television. It follows speculation that the company, which recently purchased the grocery chain Whole Foods, might use its stores as locations for pharmacies or clinics.
(We asked health care experts to imagine what the three corporations might do.)

“It could be big,” Ed Kaplan, who negotiates health coverage on behalf of large employers as the national health practice leader for the Segal Group, said of the announcement. “Those are three big players, and I think if they get into health care insurance or the health care coverage space, they are going to make a big impact.”

TAKING ON ‘THE HUNGRY TAPEWORM’
A look at the three companies that announced a joint health care initiative on Tuesday.

Total employees: 1.2 million 
Amazon: 540,000 
Berkshire Hathaway: 367,000
JPMorgan Chase: 252,000.
Individual strengths 
Amazon: logistics and technology
Berkshire Hathaway: insurance
JPMorgan Chase: finance.

Jeff Bezos of Amazon:
“The healthcare system is complex, and we enter into this challenge open-eyed about the degree of difficulty.”
Warren E. Buffett of Berkshire Hathaway:
“The ballooning costs of healthcare act as a hungry tapeworm on the American economy. Our group does not come to this problem with answers. But we also do not accept it as inevitable.”
Jamie Dimon of JPMorgan Chase:
“The three of our companies have extraordinary resources, and our goal is to create solutions that benefit our U.S. employees, their families and, potentially, all Americans.”

But others were less sure, noting that the three companies — which, combined, employ more than one million people — might still hold little sway over the largest insurers and pharmacy benefit managers, who oversee the benefits of tens of millions of Americans.

“This is not news in terms of jumbo employers being frustrated with what they can get through the traditional system,” said Sam Glick of the management consulting firm Oliver Wyman in San Francisco. He played down the notion that the three partners would have more success getting lower prices from hospitals and doctors. “The idea that they could have any sort of negotiation leverage with unit cost is a pretty far stretch.”

Even the three companies don’t seem to be sure of how to shake up health care. People briefed on the plan, who asked for anonymity because the discussions were private, said the executives decided to announce the initiative while still a concept in part so they can begin hiring staff for the new company.

Three people familiar with the partnership said it took shape as Mr. Bezos, Mr. Buffett, and Mr. Dimon, who are friends, discussed the challenges of providing insurance to their employees. They decided their combined access to data about how consumers make choices, along with an understanding of the intricacies of health insurance, would inevitably lead to some kind of new efficiency — whatever it might turn out to be.

“The ballooning costs of health care act as a hungry tapeworm on the American economy,” Mr. Buffett said in the statement. “Our group does not come to this problem with answers. But we also do not accept it as inevitable.”

Over the past several months, the three had met formally — along with Todd Combs, an investment officer at Berkshire Hathaway who is also on JPMorgan’s board — to discuss the idea, according to a person familiar with Mr. Buffett’s thinking.

The three chief executives saw one another at the Alfalfa Club dinner in Washington on Saturday, but by then each had already had dozens of conversations with the small in-house teams they had assembled. The plan was set.

Mr. Buffett’s motivation stems in part from conversations he has had with two people close to him who have been diagnosed with multiple sclerosis, according to the person. Mr. Buffett, the person said, believes the condition of the country’s health care system is a root cause of economic inequality, with wealthier people enjoying better, longer lives because they can afford good coverage As Mr. Buffett himself has aged — he is 87 — the contrast between his moneyed friends and others has grown starker, the person said.

The companies said they would initially focus on using technology to simplify care, but did not elaborate on how they intended to do that or bring down costs. One of the people briefed on the alliance said the new company wouldn’t replace existing health insurers or hospitals.

Planning for the new company is being led by Marvelle Sullivan Berchtold, a JPMorgan managing director who was previously head of the Swiss drugmaker Novartis’s mergers and acquisitions strategy; Mr. Combs; and Beth Galetti, a senior vice president at Amazon.

One potential avenue for the partnership might be an online health care dashboard that connects employees with the closest and best doctor specializing in whatever ailment they select from a drop-down menu. Perhaps the companies would strike deals to offer employee discounts with service providers like medical testing facilities.

“Each of those companies has extensive experience using transformative technology in their own businesses,” said John Sculley, the former chief executive of Apple who is now chairman of a health care start-up, RxAdvance. “I think it’s a great counterweight to what government leadership hasn’t done, which is to focus on how do we make this health care system sustainable.”

How Amazon Rattles Other Companies
The e-commerce giant’s actions – some big, like buying Whole Foods Markets; some smaller, like Amazon meal kits – have led to stock sell-offs for a wide range of businesses.

Erik Gordon, a professor at the University of Michigan’s Ross School of Business, predicted that the companies would attempt to modernize the cumbersome process of doctor appointments by making it more like booking a restaurant reservation on OpenTable, while eliminating the need to regularly fill out paper forms on clipboards.

“I think they will bring the customer-facing, patient-facing thing into your smartphone,” he said.

Amazon has long been mentioned by health care analysts and industry executives as a potential new player in the sector. While the company has remained quiet about its plans, some analysts noted that companies often use their own employees as a testing ground for future initiatives.

The entry of Amazon and its partners adds to the upheaval in an industry where much is changing, from government programs after the overhaul of the tax law to the uncertain future of the Affordable Care Act. All the while, medical costs have persistently been on the rise.

Nationwide, average premiums for family coverage for employees rose to $18,764 last year, an increase of 19 percent since 2012, according to the Kaiser Family Foundation. Workers are increasingly paying a greater share of those costs — they now pay 30 percent of the premium, in addition to high deductibles and growing co-payments.
“Our members’ balance sheets speak for themselves — health care is a growing cost at a time when other costs are either not rising or falling,” said Robert Andrews, chief executive of the Healthcare Transformation Alliance, a group of 46 companies, including Coca-Cola and American Express, that have banded together to lower health care costs.

Other major employers have also sought more direct control over their employees’ health care. Walmart contracted with groups like the Cleveland Clinic, Mayo and Geisinger, among others, to take care of employees who need organ transplants and heart and spine care. Caterpillar, the construction equipment manufacturer, sets its own rules for drug coverage, which it has said saves it millions of dollars per year, even though it still uses a pharmacy benefit manager to process its claims.

Suzanne Delbanco, the executive director for the Catalyst for Payment Reform, a nonprofit group that mainly represents employers, said controlling rising prices is especially hard in markets where a local hospital or medical group dominates. While some have tried to tackle the issue in different ways, like sending employees with heart conditions to a specific group, “it’s piecemeal,” she said.

She added, “There are so many opportunities to do this better.”

The issue is not solely a 21st-century concern: In 1915, Henry Ford became increasingly worried about the quality of health care available to his growing work force in Detroit, so he opened the Henry Ford Hospital. It is still in existence today.

Nick Wingfield reported from Seattle, Katie Thomas from Chicago and Reed Abelson from San Francisco. Michael J. de la Merced contributed reporting from London, and Emily Flitter from New York.

A version of this article appears in print on January 31, 2018, on Page A1 of the New York edition with the headline: 3 Giants Form Health Alliance, Rocking Insurers. Order Reprints| Today’s Paper|Subscribe

Prevention Revisited

The essay below is an argument for the quality of life benefits of prevention. But its conclusions about whether prevention saves money? Those conclusions are depressing.

But I want to consider it. If prevention doesn’t save money, this goes against every intuition I have ever had on the subject.

The source of this essay is worth considering. If you look below, Dr. Aaron just published a book arguing that bad foods are not so bad – in moderation. This is a conclusion I happen to agree with. I agree with “all things in moderation”.
 
For example, a primary conclusion is that insuring people makes them more, rather than less, likely to use the emergency room. But this conclusion is about insurance, not prevention, and speaks to people’s need for convenient access to health care.

Or a second example used: anti-smoking. The essay’s conclusion is outrageous: it says that society will pay more because people who stop smoking will live longer! So, if society wishes to reduce costs, a mass euthanasia program, at, say, age 67, will really do the trick!
 
I publish but do not endorse…..

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CREDIT: Essay in the New York Times

THE NEW HEALTH CARE

The essay below is depressing. But I want to consider it. If prevention doesn’t save money, this goes against every intuition I have ever had on the subject.

I definitely don’t trust the source of this essay, or its conclusions.

For example, a primary conclusion is that insuring people makes them more, rather than less, likely to use the emergency room. But this conclusion is about insurance, not prevention, and speaks to people’s need for convenient access to health care.

Or a second example used: anti-smoking. The essay’s conclusion is outrageous: it says that society will pay more because people who stop smoking will live longer! So, if society wishes to reduce costs, a mass euthanasia program, at, say, age 67, will really do the trick!

I publish but do not in any way endorse…..

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CREDIT: New York Times Essay

THE NEW HEALTH CARE

Preventive Care Saves Money Sorry, It’s Too Good to Be True

Contrary to conventional wisdom, it tends to cost money, but it improves quality of life at a very reasonable price.

By Aaron E. Carroll
Jan. 29, 2018

The idea that spending more on preventive care will reduce overall health care spending is widely believed and often promoted as a reason to support reform. It’s thought that too many people with chronic illnesses wait until they are truly ill before seeking care, often in emergency rooms, where it costs more. It should follow then that treating diseases earlier, or screening for them before they become more serious, would wind up saving money in the long run.
Unfortunately, almost none of this is true.

Let’s begin with emergency rooms, which many people believed would get less use after passage of the Affordable Care Act. The opposite occurred. It’s not just the A.C.A. The Oregon Medicaid Health Insurance experiment, which randomly chose some uninsured people to get Medicaid before the A.C.A. went into effect, also found that insurance led to increased use of emergency medicine. Massachusetts saw the same effect after it introduced a program to increase the number of insured residents.

Emergency room care is not free, after all. People didn’t always choose it because they couldn’t afford to go to a doctor’s office. They often went there because it was more convenient. When we decreased the cost for people to use that care, many used it more.
Wellness programs, based on the idea that we can save money on health care by giving people incentives to be healthy, don’t actually work this way. As my colleague Austin Frakt and I have found from reviewing the research in detail, these programs don’t decrease costs — at least not without being discriminatory.

Accountable care organizations rely on the premise that improving outpatient and preventive care, perhaps with improved management and coordination of services for those with chronic conditions, will save money. But a recent study in Health Affairs showed that care coordination and management initiatives in the outpatient setting haven’t been drivers of savings in the Medicare Shared Savings Program.

There’s little reason to believe that even more preventive care in general is going to save a fortune. A study published in Health Affairs in 2010 looked at 20 proven preventive services, all of them recommended by the United States Preventive Services Task Force. These included immunizations, counseling, and screening for disease. Researchers modeled what would happen if up to 90 percent of these services were used, which is much higher than we currently see.

They found that this probably would have saved about $3.7 billion in 2006. That might sound like a lot, until you realize that this was about 0.2 percent of personal health care spending that year. It’s a pittance — and that was with almost complete compliance with recommendations.

One reason for this is that all prevention is not the same. The task force doesn’t model costs in its calculations; it models effectiveness and a preponderance of benefits and harms. When something works, and its positive effects outweigh its adverse ones, a recommendation is made.

This doesn’t mean it saves money.

In 2009, as part of the Robert Wood Johnson Foundation’s Synthesis Project, Sarah Goodell, Joshua Cohen and Peter Neumann exhaustively explored the evidence. They examined more than 500 peer-reviewed studies that looked at primary (stopping something from happening in the first place) or secondary (stopping something from getting worse) prevention. Of all the interventions they looked at, only two were truly cost-saving: childhood immunizations (a no-brainer) and the counseling of adults on the use of low-dose aspirin. An additional 15 preventive services were cost-effective, meaning that they cost less than $50,000 to $100,000 per quality adjusted life-year gained.

But all of these analyses looked within the health care system only. If we really want to know whether prevention saves money, maybe we should take a wider perspective. Does spending on prevention save the country money over all?

A recent report from the Congressional Budget Office in the New England Journal of Medicine suggests the answer is no. The budget office modeled how a policy to reduce smoking through higher cigarette taxes might affect federal spending. It found that such a tax would cause many people to quit smoking — the desired result. In the short term, less smoking would lead to decreased spending because of reductions in health care spending for those who had smoked.
But in the long run, all of those people living longer would lead to increases in spending in many programs, including health care. The more people who quit smoking, the higher the deficit — even with the increased revenue from taxing cigarettes.

But money doesn’t have to be saved to make something worthwhile. Prevention improves outcomes. It makes people healthier. It improves quality of life. It often does so for a very reasonable price.
There are many good arguments for increasing our focus on prevention. Almost all have to do with improving quality, though, not reducing spending. We would do well to admit that and move forward.
Sometimes good things cost money.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. He is the author of The Bad Food Bible: How and Why to Eat Sinfully.

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CREDIT: https://www.npr.org/sections/thesalt/2017/11/19/564879018/the-bad-food-bible-says-your-eating-might-not-be-so-sinful-after-all

The Bad Food Bible
How and Why to Eat Sinfully
by Aaron, M.D. Carroll and Nina Teicholz
Hardcover, 272 pages

There are some surprises in your book, like milk isn’t as nutritious as some might think?

This is one of those where, if you just look at nature, we’re the only animal that consumes milk outside of the infant period. Now there’s no need for it. Part of that is politics, and the fact that the United States got involved in promoting dairy and the whole dairy industry. But there’s really no good evidence outside of the childhood period that milk is necessary. One of the things that I tried to state in the book, and this is true of all beverages with calories, you should treat them like you treat alcohol. I mean, what else are you going to do with a good chocolate chip cookie? Of course you need a glass of milk with that. That’s like dessert — it’s something you should have because you want it, not because you need it.

Raw eggs often get a bad reputation, particularly when it comes to cookie dough. How bad are they, really?

The raw egg is another one where of course there is a risk. But you have to weigh that against joy again. The truth of the matter is that if you committed to eating raw eggs in cookie dough once a week every week for the rest of your life, you’d almost never come into contact with salmonella. If you did, you’d almost never get sick. If you got sick, you’d almost never notice. Even if you noticed, it would almost never result in something serious. The chance of you actually getting seriously ill is infinitesimal. … The joy of doing those kinds of things with your kids or enjoying the process of baking is much more satisfying and will lead to greater increases in quality of life than the infinitesimal risk that you’re hurting your health in some way.
So, it sounds like there’s a lot of misinformation surrounding what food is bad for us. What’s your eating advice then?

So I think you know, in general, one thing you can do is limit your heavily processed food as much as possible. Nature intended you to get the appley goodness from an apple, not from apple juice. But the more we can do to smile, to cook for ourselves, to know where our food is coming from, to be mindful of it, the better. But we shouldn’t be so panicked and fearful and constantly believing that if we don’t do what we’ve heard from the latest expert, that we’re going to get sick and die. That is just not true.

Of course, we are staring down the barrel of Thanksgiving, which for many of us can be a moment that produces a lot of anxiety, especially food anxiety nowadays. It just feels like it’s all so fraught. I’m evil if I eat meat. I’m bad if I like Diet Coke. Food is loaded.
It’s also really important, it’s one day a year! Your health and your eating habits are not established by one day a year. It’s perfectly fine to enjoy yourself and to live! You need to weigh — in all your health decisions — the benefits and the harms. And too often we only focus on the latter. And included in benefits are joy, and quality of life and happiness. There are times when it’s a perfectly rational decision to allow yourself to be happy and to enjoy yourself. I’m not sort of giving a license for people to eat whatever they want, anytime they want. Yes, the Diet Coke, the pie, these are all processed foods. So you should think about how much you’re eating them in relation to everything else. But on the other hand, a piece of pie on Thanksgiving is not going to erase everything else you’ve done the rest of the year. Thanksgiving is easily my favorite holiday and it’s not just because of the food, but also because of the meal and the fact that you get to enjoy it with family and friends.

I’ve got to ask you, what are you having for Thanksgiving?

As much as I can cram into my body on that day. But, I love turkey, really well-done turkey. I love mashed potatoes, and stuffing and gravy, and I think pie is the greatest dessert that exists, so I’m sure I’ll be having too much of that as well.

Producer Adelina Lancianese contributed to this report.

The Dying Algorithm

CREDIT: NYT Article on the Dying Algorithm

This Cat Sensed Death. What if Computers Could, Too
By Siddhartha Mukherjee
Jan. 3, 2018

Of the many small humiliations heaped on a young oncologist in his final year of fellowship, perhaps this one carried the oddest bite: A 2-year-old black-and-white cat named Oscar was apparently better than most doctors at predicting when a terminally ill patient was about to die. The story appeared, astonishingly, in The New England Journal of Medicine in the summer of 2007. Adopted as a kitten by the medical staff, Oscar reigned over one floor of the Steere House nursing home in Rhode Island. When the cat would sniff the air, crane his neck and curl up next to a man or woman, it was a sure sign of impending demise. The doctors would call the families to come in for their last visit. Over the course of several years, the cat had curled up next to 50 patients. Every one of them died shortly thereafter.
No one knows how the cat acquired his formidable death-sniffing skills. Perhaps Oscar’s nose learned to detect some unique whiff of death — chemicals released by dying cells, say. Perhaps there were other inscrutable signs. I didn’t quite believe it at first, but Oscar’s acumen was corroborated by other physicians who witnessed the prophetic cat in action. As the author of the article wrote: “No one dies on the third floor unless Oscar pays a visit and stays awhile.”
The story carried a particular resonance for me that summer, for I had been treating S., a 32-year-old plumber with esophageal cancer. He had responded well to chemotherapy and radiation, and we had surgically resected his esophagus, leaving no detectable trace of malignancy in his body. One afternoon, a few weeks after his treatment had been completed, I cautiously broached the topic of end-of-life care. We were going for a cure, of course, I told S., but there was always the small possibility of a relapse. He had a young wife and two children, and a mother who had brought him weekly to the chemo suite. Perhaps, I suggested, he might have a frank conversation with his family about his goals?

But S. demurred. He was regaining strength week by week. The conversation was bound to be “a bummah,” as he put it in his distinct Boston accent. His spirits were up. The cancer was out. Why rain on his celebration? I agreed reluctantly; it was unlikely that the cancer would return.

When the relapse appeared, it was a full-on deluge. Two months after he left the hospital, S. returned to see me with sprays of metastasis in his liver, his lungs and, unusually, in his bones. The pain from these lesions was so terrifying that only the highest doses of painkilling drugs would treat it, and S. spent the last weeks of his life in a state bordering on coma, unable to register the presence of his family around his bed. His mother pleaded with me at first to give him more chemo, then accused me of misleading the family about S.’s prognosis. I held my tongue in shame: Doctors, I knew, have an abysmal track record of predicting which of our patients are going to die. Death is our ultimate black box.

In a survey led by researchers at University College London of over 12,000 prognoses of the life span of terminally ill patients, the hits and misses were wide-ranging. Some doctors predicted deaths accurately. Others underestimated death by nearly three months; yet others overestimated it by an equal magnitude. Even within oncology, there were subcultures of the worst offenders: In one story, likely apocryphal, a leukemia doctor was found instilling chemotherapy into the veins of a man whose I.C.U. monitor said that his heart had long since stopped.

But what if an algorithm could predict death? In late 2016 a graduate student named Anand Avati at Stanford’s computer-science department, along with a small team from the medical school, tried to “teach” an algorithm to identify patients who were very likely to die within a defined time window. “The palliative-care team at the hospital had a challenge,” Avati told me. “How could we find patients who are within three to 12 months of dying?” This window was “the sweet spot of palliative care.” A lead time longer than 12 months can strain limited resources unnecessarily, providing too much, too soon; in contrast, if death came less than three months after the prediction, there would be no real preparatory time for dying — too little, too late. Identifying patients in the narrow, optimal time period, Avati knew, would allow doctors to use medical interventions more appropriately and more humanely. And if the algorithm worked, palliative-care teams would be relieved from having to manually scour charts, hunting for those most likely to benefit.

Avati and his team identified about 200,000 patients who could be studied. The patients had all sorts of illnesses — cancer, neurological diseases, heart and kidney failure. The team’s key insight was to use the hospital’s medical records as a proxy time machine. Say a man died in January 2017. What if you scrolled time back to the “sweet spot of palliative care” — the window between January and October 2016 when care would have been most effective? But to find that spot for a given patient, Avati knew, you’d presumably need to collect and analyze medical information before that window. Could you gather information about this man during this prewindow period that would enable a doctor to predict a demise in that three-to-12-month section of time? And what kinds of inputs might teach such an algorithm to make predictions?
Avati drew on medical information that had already been coded by doctors in the hospital: a patient’s diagnosis, the number of scans ordered, the number of days spent in the hospital, the kinds of procedures done, the medical prescriptions written. The information was admittedly limited — no questionnaires, no conversations, no sniffing of chemicals — but it was objective, and standardized across patients.

These inputs were fed into a so-called deep neural network — a kind of software architecture thus named because it’s thought to loosely mimic the way the brain’s neurons are organized. The task of the algorithm was to adjust the weights and strengths of each piece of information in order to generate a probability score that a given patient would die within three to 12 months.

The “dying algorithm,” as we might call it, digested and absorbed information from nearly 160,000 patients to train itself. Once it had ingested all the data, Avati’s team tested it on the remaining 40,000 patients. The algorithm performed surprisingly well. The false-alarm rate was low: Nine out of 10 patients predicted to die within three to 12 months did die within that window. And 95 percent of patients assigned low probabilities by the program survived longer than 12 months. (The data used by this algorithm can be vastly refined in the future. Lab values, scan results, a doctor’s note or a patient’s own assessment can be added to the mix, enhancing the predictive power.)

So what, exactly, did the algorithm “learn” about the process of dying? And what, in turn, can it teach oncologists? Here is the strange rub of such a deep learning system: It learns, but it cannot tell us why it has learned; it assigns probabilities, but it cannot easily express the reasoning behind the assignment. Like a child who learns to ride a bicycle by trial and error and, asked to articulate the rules that enable bicycle riding, simply shrugs her shoulders and sails away, the algorithm looks vacantly at us when we ask, “Why?” It is, like death, another black box.

Still, when you pry the box open to look at individual cases, you see expected and unexpected patterns. One man assigned a score of 0.946 died within a few months, as predicted. He had had bladder and prostate cancer, had undergone 21 scans, had been hospitalized for 60 days — all of which had been picked up by the algorithm as signs of impending death. But a surprising amount of weight was seemingly put on the fact that scans were made of his spine and that a catheter had been used in his spinal cord — features that I and my colleagues might not have recognized as predictors of dying (an M.R.I. of the spinal cord, I later realized, was most likely signaling cancer in the nervous system — a deadly site for metastasis).
It’s hard for me to read about the “dying algorithm” without thinking about my patient S. If a more sophisticated version of such an algorithm had been available, would I have used it in his case? Absolutely. Might that have enabled the end-of-life conversation S. never had with his family? Yes. But I cannot shake some inherent discomfort with the thought that an algorithm might understand patterns of mortality better than most humans. And why, I kept asking myself, would such a program seem so much more acceptable if it had come wrapped in a black-and-white fur box that, rather than emitting probabilistic outputs, curled up next to us with retracted claws?

Siddhartha Mukherjee is the author of “The Emperor of All Maladies: A Biography of Cancer” and, more recently, “The Gene: An Intimate History.”

Microbiome Apps Personalize EAT recommendations

Richard Sprague provides a useful update about the microbiome landscape below. Microbiome is exploding. Your gut can be measured, and your gut can influence your health and well-being. But now …. these gut measurements can offer people a first: personalized nutrition information.

Among the more relevant points:

– Israel’s Weitzman Institute is the global leader academically. Eran Elinav, a physician and immunologist at the Weizmann Institute and one of their lead investigators (see prior post).
– The older technology for measuring the gut is called “16S” sequencing. It tell you at a high level which kinds of microbes are present. It’s cheap and easy, but 16S can see only broad categories,
– The companies competing to measure your microbiome are uBiome, American Gut, Thryve, DayTwo and Viome. DayTwo and Viome offer more advanced technology (see below).
– The latest technology seems to be “metagenomic sequencing”. It is better because it is more specific and detailed.
– By combining “metagenomic sequencing” information with extensive research about how certain species interact with particular foods, machine-learning algorithms can recommend what you should eat.
– DayTwo offers a metagenomic sequencing for $299, and then combines that with all available research to offer personalized nutrition information.
– DayTwo recently completed a $12 million financing round from, among others, Mayo Clinic, which announced it would be validating the research in the U.S.
– DayTwo draws its academic understandings from Israel’s Weitzman Institute. The app is based on more than five years of highly cited research showing, for example, that while people on average respond similarly to white bread versus whole grain sourdough bread, the differences between individuals can be huge: what’s good for one specific person may be bad for another.

CREDIT: Article on Microbiome Advances

When a Double-Chocolate Brownie is Better for You Than Quinoa

A $299 microbiome test from DayTwo turns up some counterintuitive dietary advice.

Why do certain diets work well for some people but not others? Although several genetic tests try to answer that question and might help you craft ideal nutrition plans, your DNA reveals only part of the picture. A new generation of tests from DayTwo and Viome offer diet advice based on a more complete view: they look at your microbiome, the invisible world of bacteria that help you metabolize food, and, unlike your DNA, change constantly throughout your life.
These bugs are involved in the synthesis of vitamins and other compounds in food, and they even play a role in the digestion of gluten. Artificial sweeteners may not contain calories, but they do modify the bacteria in your gut, which may explain why some people continue to gain weight on diet soda. Everyone’s microbiome is different.

So how well do these new tests work?
Basic microbiome tests, long available from uBiome, American Gut, Thryve, and others, based on older “16S” sequencing, can tell you at a high level which kinds of microbes are present. It’s cheap and easy, but 16S can see only broad categories, the bacterial equivalent of, say, canines versus felines. But just as your life might depend on knowing the difference between a wolf and a Chihuahua, your body’s reaction to food often depends on distinctions that can be known only at the species level. The difference between a “good” microbe and a pathogen can be a single DNA base pair.

New tests use more precise “metagenomic” sequencing that can make those distinctions. And by combining that information with extensive research about how those species interact with particular foods, machine-learning algorithms can recommend what you should eat. (Disclosure: I am a former “citizen scientist in residence” at uBiome. But I have no current relationship with any of these companies; I’m just an enthusiast about the microbiome.)

I recently tested myself with DayTwo ($299) to see what it would recommend for me, and I was pleased that the advice was not always the standard “eat more vegetables” that you’ll get from other products claiming to help you eat healthily. DayTwo’s advice is much more specific and often refreshingly counterintuitive. It’s based on more than five years of highly cited research at Israel’s Weizmann Institute, showing, for example, that while people on average respond similarly to white bread versus whole grain sourdough bread, the differences between individuals can be huge: what’s good for one specific person may be bad for another.

In my case, whole grain breads all rate C-. French toast with challah bread: A.

The DayTwo test was pretty straightforward: you collect what comes out of your, ahem, gut, which involves mailing a sample from your time on the toilet. Unlike the other tests, which can analyze the DNA found in just a tiny swab from a stain on a piece of toilet paper, DayTwo requires more like a tablespoon. The extra amount is needed for DayTwo’s more comprehensive metagenomics sequencing.

Since you can get a microbiome test from other companies for under $100, does the additional metagenomic information from DayTwo justify its much higher price? Generally, I found the answer is yes.

About two months after I sent my sample, my iPhone lit up with my results in a handy app that gave me a personalized rating for most common foods, graded from A+ to C-. In my case, whole grain breads all rate C-. Slightly better are pasta and oatmeal, each ranked C+. Even “healthy” quinoa — a favorite of gluten-free diets — was a mere B-. Why? DayTwo’s algorithm can’t say precisely, but among the hundreds of thousands of gut microbe and meal combinations it was trained on, it finds that my microbiome doesn’t work well with these grains. They make my blood sugar rise too high.

So what kinds of bread are good for me? How about a butter croissant (B+) or cheese ravioli (A-)? The ultimate bread winner for me: French toast with challah bread (A). These recommendations are very different from the one-size-fits-all advice from the U.S. Department of Agriculture or the American Diabetes Association.

I was also pleased to learn that a Starbucks double chocolate brownie is an A- for me, while a 100-calorie pack of Snyder’s of Hanover pretzels gets a C-. That might go against general diet advice, but an algorithm determined that the thousands of bacterial species inside me tend to metabolize fatty foods in a way that results in healthier blood sugar levels than what I get from high-carb foods. Of course, that’s advice just for me; your mileage may vary.

Although the research behind DayTwo has been well-reviewed for more than five years, the app is new to the U.S., so the built-in food suggestions often seem skewed toward Middle Eastern eaters, perhaps the Israeli subjects who formed the original research cohort. That might explain why the app’s suggestions for me include lamb souvlaki with yogurt garlic dip for dinner (A+) and lamb kabob and a side of lentils (A) for lunch. They sound delicious, but to many American ears they might not have the ring of “pork ribs” or “ribeye steak,” which have the same A+ rating. Incidentally, DayTwo recently completed a $12 million financing round from, among others, Mayo Clinic, which announced it would be validating the research in the U.S., so I expect the menu to expand with more familiar fare.

Fortunately you’re not limited to the built-in menu choices. The app includes a “build a meal” function that lets you enter combinations of foods from a large database that includes packaged items from Trader Joe’s and Whole Foods.

There is much more to the product, such as a graphical rendering of where my microbiome fits on the spectrum of the rest of the population that eats a particular food. Since the microbiome changes constantly, this will help me see what is different when I do a retest and when I try Viome and other tests.

I’ve had my DayTwo results for only a few weeks, so it’s too soon to know what happens if I take the app’s advice over the long term. Thankfully I’m in good health and reasonably fit, but for now I’ll be eating more strawberries (A+) and blackberries (A-), and fewer apples (B-) and bananas (C+). And overall I’m looking forward to a future where each of us will insist on personalized nutritional information. We all have unique microbiomes, and an app like DayTwo lets us finally eat that way too.

Richard Sprague is a technology executive and quantified-self enthusiast who has worked at Apple, Microsoft, and other tech companies. He is now the U.S. CEO of an AI healthcare startup, Airdoc.

====================APPENDIX: Older Posts about the microbiome =========

Microbiome Update
CREDIT: https://www.wsj.com/articles/how-disrupting-your-guts-rhythm-affects-your-health-1488164400?mod=e2tw A healthy community of microbes in the gut maintains regular daily cycles of activities. A healthy community of microbes in the gut maintains regular daily cycles of activities.PHOTO: WEIZMANN INSTITUTE By LARRY M. GREENBERG Updated Feb. 27, 2017 3:33 p.m. ET 4 COMMENTS New research is helping to unravel the mystery of how […]

Vibrant Health measures microbiome

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Microbiome Update
My last research on this subject was in August, 2014. I looked at both microbiomes and proteomics. Today, the New York Times published a very comprehensive update on microbiome research: Link to New York Time Microbiome Article Here is the article itself: = = = = = = = ARTICLE BEGINS HERE = = = […]

Microbiomes
Science is advancing on microbiomes in the gut. The key to food is fiber, and the key to best fiber is long fibers, like cellulose, uncooked or slightly sauteed (cooking shortens fiber length). The best vegetable, in the view of Jeff Leach, is a leek. Eating Well Article on Microbiome = = = = = […]

Arivale Launches LABS company
“Arivale” Launched and Moving Fast. They launched last month. They have 19 people in the Company and a 107 person pilot – but their plans are way more ambitious than that. Moreover: “The founders said they couldn’t envision Arivale launching even two or three years ago.” Read on …. This is an important development: the […]

Precision Wellness at Mt Sinai
My Sinai announcement Mount Sinai to Establish Precision Wellness Center to Advance Personalized Healthcare Mount Sinai Health System Launches Telehealth Initiatives Joshua Harris, co-Founder of Apollo Global Management, and his wife, Marjorie has made a $5 million gift to the Icahn School of Medicine at Mount Sinai to establish the Harris Center for Precision Wellness. […]

Proteomics
“Systems biology…is about putting together rather than taking apart, integration rather than reduction. It requires that we develop ways of thinking about integration that are as rigorous as our reductionist programmes, but different….It means changing our philosophy, in the full sense of the term” (Denis Noble).[5] Proteomics From Wikipedia, the free encyclopedia For the journal […]

Alzheimer’s Genetic Risk Assessment

CREDIT: NPR article

CREDIT: Bill Gates 11.13.17 Blog Post on Alzheimer’s

FDA Approves Marketing Of Consumer Genetic Tests For Some Conditions

April 7, 20171:40 PM ET
JESSICA BODDY

23andMe is now allowed to market tests that assess genetic risks for 10 health conditions, including Parkinson’s and late-onset Alzheimer’s diseases.
Meredith Rizzo/NPR
The U.S. Food and Drug Administration approved 23andMe’s personal genetic test for some diseases on Thursday, including Alzheimer’s, Parkinson’s and celiac diseases.
The tests assess genetic risk for the conditions but don’t diagnose them, the FDA says. The agency urges consumers to use their results to “help to make decisions about lifestyle choices or to inform discussions with a health care professional,” according to a press release about the decision.
Jeffrey Shuren, the director of the FDA’s Center for Devices and Radiological Health, wrote, “it is important that people understand that genetic risk is just one piece of the bigger puzzle, it does not mean they will or won’t ultimately develop a disease.” Other known factors that can play into the development of disease include diet, environment and tobacco use.

SHOTS – HEALTH NEWS
23andMe Bows To FDA’s Demands, Drops Health Claims
The FDA has previously scolded the company for marketing the personal genetic testing kits without the agency’s consent. In 2013, the agency told 23andMe to stop selling its personal genome kits in the United States until they gained FDA approval by proving they were accurate.
The company agreed to work with the FDA, as we reported, and a recent FDA review of peer-reviewed studies found more consistent links between certain gene variants and 10 diseases, the FDA says.
As a result, the FDA is now allowing 23andMe to market tests that assess genetic risks for the following 10 diseases or conditions:
▪ Parkinson’s disease, a nervous system disorder impacting movement 

▪ Late-onset Alzheimer’s disease, a progressive brain disorder that destroys memory and thinking skills 

▪ Celiac disease, a disorder resulting in the inability to digest gluten 

▪ Alpha-1 antitrypsin deficiency, a disorder that raises the risk of lung and liver disease 

▪ Early-onset primary dystonia, a movement disorder involving involuntary muscle contractions and other uncontrolled movements 

▪ Factor XI deficiency, a blood clotting disorder 

▪ Gaucher disease type 1, an organ and tissue disorder 

▪ Glucose-6-phosphate dehydrogenase deficiency, also known as G6PD, a red blood cell condition 

▪ Hereditary hemochromatosis, an iron overload disorder 

▪ Hereditary thrombophilia, a blood clot disorder 


The company’s $199 Health and Ancestry test is available directly to consumers, without seeing a physician or genetic counselor. Consumers’ DNA is extracted from a saliva sample. After mailing in their sample, people can see their results online.
“This is an important moment for people who want to know their genetic health risks and be more proactive about their health,” said Anne Wojcicki, the CEO and co-founder of 23andMe, in a company press release.
Sharon Terry, the CEO of the Genetic Alliance, a nonprofit organization that advocates for health care for people with genetic disorders, likens it to another consumer test. “Women learn they are pregnant using a test directly marketed to them and buy it off the shelf in a drugstore,” she told NPR. “In 10 years we will marvel that this is an ‘advance’ at all. Imagine pregnancy tests being only available through a doctor!”
Robert Green, a professor of medicine at Harvard Medical School, says people should be able to access genetic information in whatever way is best for them. “Some people really want this [genetic] information on their own, and others want it through their physician,” he said. “Both those channels are legitimate. People should just be aware that this information is complicated.”
But some are still concerned about whether the genes in question actually correspond to a higher risk of disease reliably enough to warrant direct-to-consumer marketing and testing, as opposed to genetic testing with the guidance of a professional.

SHOTS – HEALTH NEWS
Don’t Get Your Kids’ Genes Sequenced Just To Keep Up

SHOTS – HEALTH NEWS
Personalizing Cancer Treatment With Genetic Tests Can Be Tricky
Some health professionals worry that consumers will “take the results and run,” as Mary Freivogel put it. Freivogel, a certified genetic counselor and the president of the National Society of Genetic Counselors, added that genetics are just “one piece to the story when it comes to developing a disease.”
Freivogel said speaking with a genetic counselor before getting tested for disease is important. “Direct-to-consumer testing takes away a pre-test conversation,” she said, where counselors can help patients think about questions like: “What do you want to know? What are you going to do with this information? Is it something you’re prepared to know, or is it going to just make you anxious?”
And it isn’t clear what consumers should do with their newly calculated disease risk, especially for conditions like Alzheimer’s for which there isn’t a cure or even a course of action to prevent the disease.
What’s more, having the genes is not the same as having the diseases the genes are associated with. A person may have genes that are associated with Alzheimer’s, for example, but that doesn’t mean he or she will ever get the disease. Conversely, some people develop Alzheimer’s without the identified risk genes.
The Alzheimer’s Association does not recommend routine genetic testing for the disease in the general population because it can’t “productively guide medical treatment.”
A genetic test result for Alzheimer’s is “not going to provide useful information even if you’re at an increased risk,” said Keith Fargo, director of scientific programs at the Alzheimer’s Association. “It’s not like there’s a drug you can take right now [to prevent the disease] or a lifestyle change you can make that you shouldn’t make anyway,” such as exercising and eating right to keep your brain healthy.
John Lehr, the CEO of the Parkinson’s Foundation, says personal genetic tests can help identify risk for Parkinson’s disease. But, he wrote in a statement following the FDA’s announcement, the foundation recommends “that people who are interested in testing first seek guidance from their doctors and from genetic counselors to understand what the process may mean for them and their families.”

Anti-Dieting

This is a rather long article published in the NYT Magazine about dieting, and the new trends toward anti-dieting.

CREDIT: NYT Magazine Article in its Entirety

Losing It in the Anti-Dieting Age

The agonies of being overweight — or running a diet company — in a culture that likes to pretend it only cares about health, not size.
BY TAFFY BRODESSER-AKNER
AUG. 2, 2017

James Chambers was watching membership sign-ups on Jan. 4, 2015, like a stock ticker — it was that first Sunday of the year, the day we all decide that this is it, we’re not going to stay fat for one more day. At the time, he was Weight Watchers’ chief executive, and he sat watching, waiting for the line on the graph to begin its skyward trajectory. Chambers knew consumer sentiment had been changing — the company was in its fourth year of member-recruitment decline. But they also had a new marketing campaign to help reverse the generally dismal trend. But the weekend came and went, and the people never showed up. More than two-thirds of Americans were what public-health officials called overweight or obese, and this was the oldest and most trusted diet company in the world. Where were the people? Weight Watchers was at a loss.
Chambers called Deb Benovitz, the company’s senior vice president and global head of consumer insights. ‘‘We’re having one of the worst Januaries that anyone could have imagined,’’ she remembers him telling her. In the dieting business, January will tell you everything you need to know about the rest of the year. ‘‘Nothing like we had anticipated.’’ Chambers and Benovitz knew that people had developed a kind of diet fatigue. Weight Watchers had recently tried the new marketing campaign, called ‘‘Help With the Hard Part,’’ an attempt at radical honesty. No one wanted radical honesty. Chambers told Benovitz that they needed to figure out what was going on and how to fix it before the February board meeting.
Benovitz got to work. She traveled the country, interviewing members, former members and people they thought should be members about their attitudes toward dieting. She heard that they no longer wanted to talk about ‘‘dieting’’ and ‘‘weight loss.’’ They wanted to become ‘‘healthy’’ so they could be ‘‘fit.’’ They wanted to ‘‘eat clean’’ so they could be ‘‘strong.’’
If you had been watching closely, you could see that the change had come slowly. ‘‘Dieting’’ was now considered tacky. It was anti-feminist. It was arcane. In the new millennium, all bodies should be accepted, and any inclination to change a body was proof of a lack of acceptance of it. ‘‘Weight loss’’ was a pursuit that had, somehow, landed on the wrong side of political correctness. People wanted nothing to do with it. Except that many of them did: They wanted to be thinner. They wanted to be not quite so fat. Not that there was anything wrong with being fat! They just wanted to call dieting something else entirely.

A study out of Georgia Southern University’s Jiann-Ping Hsu College of Public Health, published in The Journal of the American Medical Association in March, monitored attitudes toward losing weight over three periods between 1988 and 2014. In the first period, 1988-94, 56 percent of fat adults reported that they tried to lose weight. In the last period, 2009-14, only 49 percent said so.
The change had been spurred not just by dieting fatigue but also by real questions about dieting’s long-term efficacy. In Weight Watchers’ own research, the average weight loss in any behavior-modification program is about a 5 percent reduction of body weight after six months, with a return of a third of the weight lost at two years. There were studies that appeared to indicate that the cycle of weight loss and weight gain could cause long-term damage to the metabolism. Those studies led to more studies, which suggested that once your body reaches a certain weight, it is nearly impossible to exist at a much lower weight for an extended period of time. Even more studies began to question whether or not it’s so bad to be fat in the first place; one notably suggested that fatter people lived longer than thin ones.
These questions began to filter into the mainstream. Women’s magazines started shifting the verbal displays on their covers, from the aggressive hard-body stance of old to one with gentler language, acknowledging that perhaps a women’s magazine doesn’t know for sure what size your body should be, or what size it can be: Get fit! Be your healthiest! GET STRONG! replaced diet language like Get lean! Control your eating! Lose 10 pounds this month! In late 2015, Women’s Health, a holdout, announced in its own pages that it was doing away with the cover phrases ‘‘drop two sizes’’ and ‘‘bikini body.’’ The word ‘‘wellness’’ came to prominence. People were now fasting and eating clean and cleansing and making lifestyle changes, which, by all available evidence, is exactly like dieting.
Diet companies suffered for being associated with dieting. Lean Cuisine repositioned itself as a ‘‘modern eating’’ company, not a diet company. In fact, Lean Cuisine went so far in their pivot that in 2016 they introduced a Google Chrome extension that would filter mentions of the word ‘‘diet’’ and ‘‘dieting’’; it apparently did this to show that just because it was called Lean Cuisine, that didn’t mean it was a diet company. You can’t be held responsible for what your parents named you!
Weight Watchers saw all this happening and concluded that people didn’t have faith in diets. The company decided that what it offered was not a diet program but a lifestyle program. It was a behavior-modification program. (For the sake of expediency here, I will call its program a diet because it prescribes amounts of food.) When Deb Benovitz returned from her travels with news of dieting’s new language changes, the company realized that something had to change more than its marketing approach.
Weight Watchers’ chief science officer is Gary Foster, a psychologist — the first in that position, which previously had been held by dietitians. What he and his team realized from Benovitz’s research was that dieters wanted a holistic approach to eating, one that helped really change their bodies, yes, but in a way that was sustainable and positive. He got to work creating a new approach that would become known as Beyond the Scale: He used all available mind-body research to try to figure out a way for members to appreciate benefits of the program besides weight loss. This would help them stay on the program during setbacks and beyond their weight-loss period and allow the program to infiltrate their lives beyond mealtime and beyond plain old eating suggestions.
The company would move away from giving its members goal weights. It expanded its cognitive-behavioral strategies, which taught members to challenge unhelpful thinking and to respond to their emotions with reason, as opposed to with food or despair. It developed workshops that used meditation and qigong and didn’t once mention food or weight. It updated its apps and introduced a social-media program, Connect. It became as holistic-minded as the people told Benovitz they wanted a program to be.
But Weight Watchers was still a company called Weight Watchers, and it had to figure out a way to communicate all of this change to the public. People had too many associations with the brand. It needed someone other than the usual celebrity spokesdieter, a fat famous person who could be paid somewhere between $250,000 and $2 million to do the talk show circuit and People covers for a year. It needed someone who could fast-track the message that it was worth taking a new look at Weight Watchers.
When the company called Oprah Winfrey in July 2015, she was standing on the lawn of her home in Maui with a sprained ankle, an injury she sustained while hiking in the mountains. In the month since her convalescence began, she had gained 17 pounds. Her struggles with weight were, at this point, a cultural meme. How could you explain the failure of someone so goal-oriented and successful — someone so successful that her name was invoked as a symbol of success as often as it was ever used to summon her? Weight Watchers had reached out to her in the past, but she politely declined. This time she bought a 10 percent stake in the company for $43 million, and Weight Watchers stockholders rejoiced.
But the verbal changes around dieting had indicated something deeper than just a marketing issue; they pointed straight back to the fatigue that was hurting Weight Watchers in the first place. So, yes, many people celebrated the new partnership. But others — meaning, anyone who for a majority of their lives had been watching Oprah cycle up and down through different sizes — felt a little confused by the move. What was Oprah, a person whose very brand meant enlightenment and progress, doing on another diet? It was hard not to suspect that she was trapped, like so many of us are, in a culture that says one thing about fatness and means something very different.

Back in 1963, when Jean Nidetch held the first what-would-be-known-as-Weight-Watchers meetings above a movie theater in Queens, things seemed clearer: It was bad to be fat, and it was good to be thin, and fat people wanted to be thin, and thin people wanted to help them get there. Her memoirs, ‘‘The Story of Weight Watchers,’’ reads about as current as a cigarette ad featuring smoking babies. ‘‘If strawberry shortcake made you break out in purple spots, you wouldn’t eat it,’’ she wrote. ‘‘You’d be allergic to it. But, do you think fat is prettier than purple spots? It’s uglier and harder to get rid of.’’
Its frankness seems like an anachronism now, but you have to consider that at the time, this kind of straight talk was a glass of cold water in the desert for many fat people, who privately wondered why it was so hard for them to reduce the size of their bodies when it seemed so effortless for the people who walked around thin. Nidetch lost her weight in her late 30s, after a lifetime of self-loathing and embarrassment; the last indignity was the time someone asked when her baby was due when she was definitively not pregnant. She went to a city-run obesity clinic, and when she left the program, she kept the diet it gave her. She mimeographed it and handed it out to people whom she had gathered to spread the word about how weight loss could provide freedom and hope. (The diet would evolve from an eating plan to a more democratic system of balanced exchanges to an absolute laissez-faire system of points, as the company realized that the more autonomy and the less deprivation people experienced in their dieting — limitless choices, if not limitless amounts — the more likely they’d be to stay on the diet.) But Nidetch knew that it wasn’t just the food that was the problem; it was the problem that was the problem. What fat people needed was one another. They needed a space in which they could talk openly about the physical struggles and daily humiliations of walking around in a fat body, and just how much that sucked.
These same ideas were articulated more starkly a few years later, but with a different prescription. In 1967, a fat man named Lew Louderback unleashed an essay in The Saturday Evening Post arguing that the wisdom around thinness could be applied only to thin people — that fat people suffered physically and psychologically when trying to maintain thin-person weights, and that this maintenance seemed to be temporary at best and largely destructive emotionally.
He went on to write a book called ‘‘Fat Power,’’ which helped give birth to what would become known as the fat-acceptance movement. That movement has varying degrees of militancy, but generally asks the public to put aside its bias and learn something new — to not think of fat people as lazy; to not deny them medical care; to not exclude them from their basic rights. It suggests that we re-examine what we think we know about fatness, that we consider trying to love and care for our bodies at whatever size they are now.

There were more books and more essays and more challenges to the status quo in the decades to come. In 2008, Linda Bacon, a researcher who holds graduate degrees in physiology, psychology and exercise science with a specialty in nutrition, wrote a seminal fat-acceptance book, ‘‘Health at Every Size: The Surprising Truth About Your Weight,’’ which used peer-reviewed research to bolster these ideas. She gave seminars to doctors on fat phobia and weight bias in an effort to help them understand how their views on obesi­ty were hurting their patients and not allowing them to examine fatness neutrally. For example, there is evidence that stress and discrimination play a strong role in the insulin resistance and diabetes and heart disease for which weight typi­cally takes the blame.
With the rise of social media, the movement began to infiltrate the culture in other ways, too. Fat-acceptance and body-positivity activists began posting pictures of themselves on Instagram — just regular pictures, defiant for their lack of apology. There were intuitive-eating workshops and body-positivity training camps. There were bloggers and authors asking exactly how much of your life you were willing to put off in pursuit of a diet, or until you got to a certain weight, even temporarily. Normal, nonmilitant, nonactivist people began asking themselves if it was that bad to be fat — if it was that unhealthy, or that ugly, to be fat. And yet the most telling thing about the way the fat-acceptance movement is received in our society may be that its Wikipedia entry contains two quotes from people criticizing it before it mentions even one person who espouses it. In this world, we are witness to a moment when the word “optimal” is used in conjunction with the word “body,” when people are trying to mold themselves into high-performance, precision machines. The idea of a fat machine makes no sense when you are easily fueled and refueled on Whole Foods and Soylent.
In other words, all this activism didn’t make the world more comfortable with fat people or dieting. Society doesn’t normally change the words for things unless we’re fundamentally uncomfortable with the concepts beneath them. Consider the verbal game of chicken we’ve played with the people all this affects: Fat people went from being called fat (which is mean) to being called overweight (a polite-seeming euphemism that either accidentally or not accidentally implies that there is a standard weight) to being called zaftig/chubby/pleasingly plump (just don’t) to curvy (which seems to imbue size with a sexuality and optimism where it should just be sexually and emotionally neutral) and back to fat (because it’s only your judgment of fat people that made it a bad word in the first place, and maybe being fat isn’t as bad as we’ve been made to believe). It bears mentioning that Weight Watchers doesn’t have a standardized word for its demographic, but Foster uses the term ‘‘people with overweight.’’
As the ideas that sprang from the fat-acceptance movement began to trickle into the mainstream, fat people began to wonder what it might be like to put all this aside and just live their lives. Some asked themselves if they thought they could figure out a way to not want to be thin; some began to ask themselves if they actually liked the way they looked. They began to wonder if there was even a proven and effective way to become and stay thin anyway. They began to ask themselves if they should be dieting at all.

Last fall, I was with Foster, Weight Watchers’ chief science officer, as he walked the halls of Obesity Week, the annual conference of the Obesity Society. The conference includes study presentations, each one a possible clue to the mystery of fatness. We attended a presentation on a new study of a weight-loss medication. People on the medication lost weight, but once they were off, the weight came back. If only we could get people’s weight down, the presenters said, they could have a fresh start. Out in the hall, Foster shook his head. ‘‘There’s a bias and a stigma: ‘We’ll give these people medication for a short period, but then they’ve got to fly straight and get will power.’ It’s nonsense. This tough love — I’m going to be hard on myself — you know, in some perverse way, if it were true, we might try to leverage it, but it’s not. The harder you are on yourself, the worse you do.’’ In his career before Weight Watchers, Foster was the founder and director of the Center for Obesity Research and Education at Temple University. Neutralizing the morality talk and stigma that surround obesity, he says, would make it a lot easier to figure out how to deal with it.
By the time of the conference, the Oprah-Weight Watchers partnership had proved a clear success. Within a year, the company was up to 2.8 million members; by the first quarter of 2017 it would be 3.6 million. Oprah had brought an audience to Beyond the Scale, the holistic model Foster helped create. He says that initial weight loss on the program in 2016 was up 15 percent from what it was the year before. Of course people should want to manage their weight, he said, the same way they’d want to manage their diabetes. ‘‘It would seem preposterous if we would say to people with diabetes, ‘Don’t manage your diabetes.’ ’’ Or their asthma. All three are chronic conditions; why, he asks, would we assume we should give up on weight? When people lose weight, he points out, they see improvements in risk factors. Data is data. Modifying your eating is hard, he says, but it’s worth it. No one can tell you that lowering weight doesn’t also lower other health factors like hypertension and high cholesterol and joint pain.
Some fat people began to wonder if there was even a proven and effective way to become and stay thin anyway. They began to ask themselves if they should be dieting at all.

Maybe that’s true. Most mainstream sources agree on this, but there are definitely some researchers who don’t; there are some who think that people who end up fat have different physiologies, and that fatness is just one component of them. Consider the ‘‘uptick,’’ as Foster calls it, that comes after two years on a diet when, say, the person who lost 5 percent of her weight has gained a third of it back. Think about those numbers. If you weigh 300 pounds, you will lose 15 pounds in six months. You’ll keep it off for a year or two, maybe. Five pounds is likely to return. Of course, these are people who don’t stay on a diet-maintenance plan; but the average dieter certainly doesn’t, and it’s worth it to ask why a person wouldn’t stay on a program that offered such rewards. Is it because they couldn’t? It’s worth it to ask if the programs are right and all these humans trying very hard at them are wrong. And also, where are the 300-pound people who want to lose just 15 pounds in the first place? I haven’t met those people. But mainly, what it comes down to is this: Weight Watchers is designed to be successful only if you can stay on Weight Watchers forever.
And there were also questions about dieting’s long-term effects on the body. A study done by the National Institute of Diabetes and Digestive and Kidney Diseases, which is part of the National Institutes of Health. The study followed contestants who had appeared on the eighth season of ‘‘The Biggest Loser,’’ all of whom had normal resting metabolisms for their size when the season began. As the contestants experienced radical, sweeps-week weight loss, their metabolisms slowed, and stayed slow afterward. To maintain his weight loss, one contestant’s resting metabolism now required 800 calories fewer per day than a man of his size. It might be that when you have been fat, your body doesn’t behave the way a thin body does, even when you become thinner.
Foster shook his head at that one. He hears about the ‘‘Biggest Loser’’ study a lot, but he doesn’t think it conveys accurate information. It uses a very small sample under extreme conditions. He cited his own and others’ studies examining the metabolic rate, fat distribution and psychological state of people before they lose weight, after they lose weight and after they regain the weight. ‘‘Nothing is changed,” he said. ‘‘I’m not saying that’s a good outcome or something we should celebrate — but this idea that the act of managing your weight and losing weight has somehow set you up to be in a worse spot just isn’t borne out by the science.’’
Here is the thing about this particular debate at this particular moment: Everyone has much the same data, but there are plenty of people who would interpret the data differently from the way Foster does. I’ve spoken to countless (I literally stopped keeping count) obesity researchers and dietitians and biologists and doctors. The answer becomes one of point of view: Is fat inherently bad, or can it be neutral?
We can’t answer that yet. There is still too much debate. So in the meantime, a fat person has to consider the data she has access to — meaning studies, yes, but also her own experience and the experience of her fat peers — and ask: Do you believe that you, a fat person, can ever be meaningfully thinner for a meaningful amount of time? Is a diet successful if it stops being successful once you’re done with it? I’ve interviewed Foster before. Back in 2011, when he was at Temple, he published a study about the efficacy of different kinds of diets. They all led to similar losses, and they all led to similar rates of recidivism. When I spoke with him back then, I asked him why we should continue dieting if the outcomes were so bad. He was concerned that I would suggest to my readers that dieting wasn’t worth it. He told me that people didn’t need that kind of discouragement. This attitude is what makes him so credible to me — his message was the same long before he worked for a corporation — but it’s also what makes this so depressing.
I do not recommend being a fat person at Obesity Week. Over the years, the event has become a week long, and it contains a robust trade show. After Foster left me to go to a meeting, I walked the trade-show floor and saw all the products being shown to the obesity specialists in attendance. I watched a video of a new kind of retractor that will more easily hold open belly skin while part of a stomach is cut out and sewn up, because you can’t eat as much if your stomach is made smaller. I watched a person showing a model of a balloon you’d insert into the stomach of a patient that would take up volume so that she wouldn’t be so hungry, to be removed later once her behavior had been modified. I drank a smoothie with a superfood ingredient I can’t pronounce or remember while someone told me that my readers would really be interested in their something-metrics plan for hydration and portion control. I narrowed my eyes thoughtfully because it felt rude to be drinking this guy’s smoothie without taking him seriously. ‘‘There’s no such thing as magic, Taffy,’’ the smoothie man was saying. I nodded in solemn agreement.
Before he left me, I told Foster that Obesity Week made me sad. First, it was the profusion of educated people in the room studying me and my people as if we were problems to solve. But second, it was because if you have this many hundreds of smart and educated people trying to figure this out, and nobody has anything for me but superfood and behavior modification and an insertable balloon and the removal of an organ, it must be that there is no way to solve fatness.
Foster doesn’t see it that way, he told me. ‘‘I look around this room,’’ he said, ‘‘and I see hope.’’

By the time Oprah announced that she was signing on with Weight Watchers, I was celebrating my 25th anniversary of my first diet, at age 15, which I found in an issue of Shape magazine. I was 5-foot-3 and weighed 110 pounds. In the intervening years, I did cleanses and had colonics and refilled the prescriptions on three rounds of those diet pills that made my teeth sweat and ate two shakes for lunch and just protein and just good carbs (carbs are divided into good and bad, like witches in Oz) and just liquid and just fruit until dinnertime and just food the size of my fist and two glasses of lukewarm lemon water. I had stood up in a room and said, ‘‘Hello, my name is Taffy, and I am a compulsive overeater.’’ I had stuck my finger down my throat, a shot in the dark that I hoped would be more sustainable than it was. I had South Beached, I had Atkinsed, I had Slim-Fasted. Put it this way: The Amazon algorithm recently recommended to me, based on my previous searches, a book-and-CD combination, ‘‘Hypnotic Gastric Band: The New Surgery-Free Weight-Loss System,’’ which offered a hypnotic equivalent to bariatric surgery. Put it this way: When I arrived at Weight Watchers, despite the fact that I was there as a journalist, I registered for the diet under the ra­tion­ale that this was experiential journalism. When I gave my name at the counter, the person registering me furrowed her brow and said: ‘‘That’s strange. There are three other people named Taffy Akner.’’ I said, ‘‘No, those are all me.’’
‘‘In Brooklyn?’’
‘‘Yes, when I was in high school.’’
‘‘In Los Angeles?’’
‘‘Yes, right before I was married.’’ I stopped her before she could go on. ‘‘They’re all me.’’

By then I was all in, as if I ever hadn’t been. When I arrived at the Union, N.J., meeting at 8 a.m. on a Saturday, it was a few weeks before Thanksgiving. Thanksgiving is marketed as a fun, festive holiday of family gathering, but everyone at that meeting knew the truth: Thanksgiving is an existential threat. Thanksgiving is a killer.
The year leading up to Thanksgiving hadn’t been much better for this group. There had been family deaths and illness. There had been foreclosures and unemployments and high-school reunions, and someone’s daughter was always baking sticky buns; someone’s husband wanted to know where his steak was; someone’s son wanted to know why the meatloaf tasted different; someone’s co-worker was always leaving doughnuts and bagels on the communal table at the office. The people, mostly women, in the folding chairs had one rule, though: No matter what happened during the week, you showed up. ‘‘This is my church,’’ a woman named Donna told me. A few months before, she buried her mother on a Friday; on Saturday she came to the meeting.
Dayna, the group leader, stood at the head of the room. How could you not love Dayna? She took such care with her appearance — she wore tall boots and wrap dresses and makeup, even on Saturday mornings when everyone else wore sweatpants at best (or leggings; leggings weigh less). She gave them star-shaped stickers off a large roll when they lost weight or when they had acted in their best interests over the week. She remembered their names, even the ones who hadn’t shown up in months; she gave them hugs.
Today, Donna had gained weight. She had been holding steady at six pounds short of her goal. Since 2009 — 2009 — she had shown up every week and by now had lost 132 pounds, which is an entire other Donna. But these last six pounds, my God, what would it take? She’d been down last week by a pound, and now that pound was back. She’d been going to the gym ‘‘religiously’’ for two weeks, but thought maybe the not going to the gym three weeks ago had caught up with her. Sometimes being six pounds away from her goal was harder than being 321 pounds.
‘‘I’m so frickin’ aggravated,’’ she said. She asked me how I did. I shrugged and told her I had lost three pounds. ‘‘But I just started, so, . . . ’’ I said. I didn’t want her to feel bad. Another woman, Amy, whispered to me, ‘‘You never want to say ‘I only lost, . . . ’ because then everyone will go, ‘Oh, jeez.’ ’’
Weight isn’t neutral. A woman’s body isn’t neutral. A woman’s body is everyone’s business but her own.

I asked the women there, most of whom were repeat joiners as well: Shouldn’t we be moving toward acceptance? Here we all were — smart, accomplished, successful women (and one man) — and we couldn’t maintain what was proved to be the most effective diet you could ever try. If we couldn’t stay on this, could we stay on anything? What if the flaw wasn’t in us but in the system?
They furrowed their brows and shook their heads and gave me funny looks. What was I talking about? How could a fat person not want to be thin? Donna’s sisters were all on diabetes medication, and she wasn’t. Her back had hurt until about 20 pounds ago, and now she could crawl on the floor with her grandson as if it were nothing.
I couldn’t counter very hard. Each time I came to a meeting, I was seduced by the possibility, by the clean, Calvinist logic, that if you ate less you would weigh less, that your body would feed on itself and its fat reserves until you became smaller and smaller and more pleasing to the world and its standards — until you practically disappeared (we are a culture that fetishizes something called Size 0). I looked forward to these meetings, feeling as if these people were the only ones who seemed to truly understand my predicament. But my optimism and motivation didn’t survive my walk out the door. By the time I got to my car, I had no idea what to do. I knew that if this could be done, I would have done it, and yet I didn’t know why I couldn’t do it. Just eat less, right? It’s so simple!
About two years ago, I decided to yield to what every statistic I knew was telling me and stop trying to lose weight at all. I decided to stop dieting, but when I did, I realized I couldn’t. I didn’t know what or how to eat. I couldn’t fathom planning my food without thinking first about its ability to help or hinder a weight-loss effort. I went to a nutritional therapist to help figure this out (dieting, I have found, is its own chronic condition), and I paid her every week so I could tell her that there still had to be a way for me to lose weight. When she reminded me that I was there because I had realized on my own that there was no way to achieve this goal, I reminded this wonderful, patient person that she couldn’t possibly understand my desperation because she was skinny. I had arthritis in my knees, I said. Morality and society aside, they hurt. I have a sister with arthritis in her knees, too, but she’s skinny and her knees don’t hurt.
I went to an intuitive-eating class — intuitive eating is where you learn to feed yourself based only on internal signals and not external ones like mealtimes or diet plans. Meaning it’s just eating what you want when you’re hungry and stopping when you’re full. There were six of us in there, educated, desperate fat women, doing mindful-eating exercises and discussing their pitfalls and challenges. We were given food. We would smell the food, put the food on our lips, think about the food, taste the food, roll the food around in our mouths, swallow the food. Are you still hungry? Are you sure? The first week it was a raisin. It progressed to cheese and crackers, then to cake, then to Easter candy. We sat there silently, as if we were aliens who had just arrived on Earth and were learning what this thing called food was and why and how you would eat it. Each time we did the eating exercise, I would cry. ‘‘What is going on for you?’’ the leader would ask. But it was the same answer every time: I am 41, I would say. I am 41 and accomplished and a beloved wife and a good mother and a hard worker and a contributor to society and I am learning how to eat a goddamned raisin. How did this all go so wrong for me?
They tried to soothe me. They told me that hatred of fat was a societal construct, but I never understood why that should comfort me. I live in society. I hurt my ankle playing tennis, activating an old injury, and an internist I was seeing for the first time, without taking any medical history or vital signs — my blood pressure is pristine, just so you know — told me he couldn’t do anything for me until I lost weight and gave me a rusty photocopy about food exchanges. (Another doctor prescribed three months of physical therapy, and now my ankle is fine.) I was in Iceland, for a story assignment, and the man who owned my hotel took me fishing and said, ‘‘I’m not going to insist you wear a life jacket, since I think you’d float, if you know what I mean.’’ I ignored him, and then afterward, back on land, after I fished cod like a Viking, he said, ‘‘I call that survival of the fattest.’’ A woman getting into a seat next to me on a plane said, ‘‘Looks like this will be a cozy ride,’’ and a Manhattan taxi driver told me he liked to watch my ‘‘jelly’’ shake, by which I can only presume he meant a part of my body. I have been asked if it was my first time taking Pilates at a studio where I’m on my fifth 10-pack. I have been told at a yoga class that I have ‘‘a really great spirit’’ and it’s important that I ‘‘just keep coming.’’ (I’ve been taking yoga for 12 years.) I was told by a seamstress that she had never seen a bride not lose weight for her wedding until she met me. A crazy man tried to give me candy outside the Met, and when I politely declined he screamed at me that of course I didn’t want it, I was fat enough, and my sister asked me why I was so upset, clearly that guy was crazy, and I said, ‘‘You don’t understand because you’re skinny,’’ and on and on forever. (By the way, I am writing this despite the myriad degradations that I know will appear in my inbox and in the comments section when it is published. I am someone who once wrote a body-image essay for a women’s magazine in which a comment in the margins from an editor read, ‘‘Why doesn’t she stop eating so much?’’)
Back in Union, Dayna stood at the front of the room. The conversation had shifted to Thanksgiving foods, how sons home from college depend on the stuffin’ muffins, how husbands will know if there’s no butter in the mashed potatoes. Donna makes an Easter pie with more kinds of pork than there are pigs roaming the Earth. Really, the group members were worried that despite their weight loss, they would forget that they were really fat people on the inside. Thanksgiving is a killer.
‘‘It’s just one day,’’ Dayna said. And all those around her heaved heavy sighs.
‘‘Please hold for Ms. Winfrey.’’
When Oprah called me, she was on the same mountain in Hawaii where she sprained her ankle two years ago. After a monthslong search, Weight Watchers had hired a new C.E.O., Mindy Grossman, formerly of the Home Shopping Network. In her office, Grossman had talked to me about personalizing the company’s mobile app and creating greater moments for connection. She is tan and very blond, with pink lipstick; she looks like the second coming of Jean Nidetch. Weight Watchers had found its business leader. She was joining the company after its fourth consecutive quarter of revenue growth because it had finally found its spiritual one.
On the release day of the commercial in which Oprah told the world she loved bread and was excited to be able to eat it every day and still lose weight, the graph line shot up tall and straight at Weight Watchers. But a lot of us wondered if maybe Oprah had finally fallen out of touch. She said in one commercial, ‘‘Inside every overweight woman is a woman she knows she can be,’’ saying she’d been buried in her weight to the point where she couldn’t recognize herself, and the internet did not love this sentiment, asking exactly why Oprah thought that women were worthless if they weren’t thin. They asked if she was ‘‘disempowering women.’’ They said her investment in Weight Watchers was ‘‘bad news for women everywhere.’’ One blogger wrote that she was ‘‘disappointed that she is choosing to participate in and endorse a company whose sole purpose is to tell women that they are not enough.’’ The journalist Melissa Harris-Perry gave a five-minute ‘‘Letter of the Week’’ on MSNBC saying: ‘‘But, O! You are already precisely the woman so many are striving to be,’’ and ‘‘there is not one thing that you have done that would have been more extraordinary if you’d done it with a 25-inch waist.’’ Oprah’s $43 million investment was now worth $110 million. Maybe that’s what this was all about in the first place.
They tried to soothe me. They told me that hatred of fat was a societal construct, but I never understood why that should comfort me. I live in society.

Oprah was used to criticism. Back in 1985, Joan Rivers brought Oprah on ‘‘The Tonight Show,’’ and without so much as a warning in the pre-interview, told her she shouldn’t have ‘‘let’’ her weight gain happen to her. ‘‘You’re a pretty girl, and you’re single,’’ Rivers said. Oprah explained that she had done everything so far — everything! By 1985! She had done the banana-hot-dog-egg diet (in which you just eat a banana and a hot dog and an egg). She had done the pickles-and-peanut-butter diet (in which all you eat are pickles and peanut butter).
In 1988, she pulled a wagon full of fat onto the stage of her show to show off her 67-pound weight loss. In 1991, she went on the cover of People and declared she was never dieting again. In 1996 she wrote a book with Bob Greene about having found the solution. In 2002, she wrote a story in her magazine, O, called ‘‘What I Know for Sure About Making Peace With My Body,’’ in which she announced that she had made peace with her body. In 2005, the cover of O, which usually features just one Oprah, featured two: a thin one with an exposed midriff leaning on the shoulder of another thin one in a fancy dress. In 2009, she published another two-Oprah cover. This one was the midriff-bearing one from the 2005 cover, leaning on a larger Oprah in a purple jogging suit. The cover line said, How did I let this happen again?
Oprah sounds like Oprah when you talk with her — she sings your name, ‘‘Taffy!’’ and her voice registers in you in a way that is as familiar to your body as your mother’s voice. She told me she doesn’t care if she’s never skinny again. She cares that she feels as if she has control. For her whole life, she said, her only goal has been to find a higher level of consciousness, to remain more in the moment than she has ever been in any other moment. She had never felt stress, even during all those years when she was doing three shows a day. She just ate instead. She had bags of potato chips, and people would say, ‘‘Don’t you get stressed?’’ and she’d think, What’s stress? She had seen the cultural changes for years. She knew that you were no longer supposed to say that you wanted to diet or be thinner. You had to want ‘‘fitness’’ and ‘‘strength’’ and just general health. But this thinking was a prison. So was the one where you just accept yourself and move on. “This whole P.C. about accepting yourself as you are — you should, 100 percent,” she said. But it was that thinking that made her say yes to Weight Watchers. ‘‘It’s a mechanism to keep myself on track that brings a level of consciousness and awareness to my eating. It actually is, for me, mindful eating, because the points are so ingrained now.’’ Meaning, Oprah wasn’t interested in ceding to a movement. She was wondering how to finally make this work.
‘‘In the particular moment in time that I got the call,’’ she told me, ‘‘I was desperate: What’s going to work? I’ve tried all of the green juices and protein shakes, and let’s do a cleanse, and all that stuff. That doesn’t work. It doesn’t last. What is going to be consistent, keep me conscious and mindful?’’
But this thing about acceptance? Why couldn’t accepting herself mean not accepting her weight? Why wasn’t it an act of love to use any available means to avoid her genetic predisposition to diabetes? Sure, she could have abandoned her efforts. She could have gone hard on acceptance. A million people would have bought ‘‘Oprah’s Guide to Body Acceptance.’’ But she couldn’t get there. ‘‘For your heart to pump, pump, pump, pump, it needs the least amount of weight possible to do that,’’ she said. “So all of the people who are saying, ‘Oh, I need to accept myself as I am’ — I can’t accept myself if I’m over 200 pounds, because it’s too much work on my heart. It causes high blood pressure for me. It puts me at risk for diabetes, because I have diabetes in my family.’’
I nodded into the phone because I didn’t want Oprah to hear me crying. I wanted to quit dieting, but had come to realize that dieting was all I had. I was completely perplexed by food — food! Stupid food! That’s what this was about! I dieted because I wanted to maintain hope that I could one day manage my food intake, because my bewilderment around the stuff was untenable. When I didn’t have that hope, I was left with too much worry about pain, about how much my knees hurt now and how much more they would in just a few years. I could be enlightened about my body. I could have acceptance. But nobody would tell that to the people who saw me as a target; nobody would tell that to my knees.
And yet, I told Oprah, in admitting this, I couldn’t stop feeling as if I were betraying everyone I knew who was out there trying to find peace with herself. I couldn’t stop thinking that nothing would change in the world until there was a kind of uprising.
‘‘Oh, my God, Taffy,’’ Oprah said. ‘‘I have to have a talk with you. I used to say this to my producers all the time. We are never going to win with this show looking back to see what other people are doing on their shows. The only way you win is to keep looking forward for yourself. What’s best for you?’’
The ‘‘you’’ threw me. I didn’t know if she meant ‘‘you’’ as in my body or ‘‘you’’ as in me, and it occurred to me that she could mean both, that some people think of those two things as the same thing. I treated my body with such contempt, but my body wasn’t different from me. There were no two of me to put on a magazine cover, just the one of me.
Weight isn’t neutral. A woman’s body isn’t neutral. A woman’s body is everyone’s business but her own. Even in our attempts to free one another, we were still trying to tell one another what to want and what to do. It is terrible to tell people to try to be thinner; it is also terrible to tell them that wanting to lose weight is hopeless and wrong.
I don’t know if diets can work in the short term or the long term. For the first time, I began to think that this was something worth being made crazy over. Our bodies deserve our thoughts and our kindness, our acceptance and our striving. Our bodies are what carry our thoughts and our kindness and our acceptance and striving.
On Saturday, March 18, Donna, of the meeting in Union, made her goal weight. Six weeks later, having maintained the weight, she became a lifetime member. If she stayed within a few pounds of her goal, she could keep using the program free. There were other lifetime members in our meeting. There were also former lifetime members who were starting over.
Eileen, a lifetime member who sat next to Donna at every meeting, had bought her a plastic tiara. Donna wore leggings this time, not sweatpants as usual, with her traditional Uggs and a fleece, and someone pointed out that you could finally see her shape. She passed around some old pictures; she was unrecognizable in them, if you could find her behind all the other people in the picture.
‘‘I don’t think I’ll ever feel like a thin person,’’ Donna said. Her hope is that she’ll continue to at least look like one.

Dayna, near sobbing, gave her a bunch of star stickers off her roll. ‘‘My heart just feels so happy today,’’ she said.
We all cheered for Donna, and when I left, I walked around outside. A skinny woman was eating a cupcake and talking on her phone, tonguing the icing as if she were on ecstasy. Another skinny woman drank a regular Dr Pepper as if it were nothing, as if it were just a drink. I continued walking and stopped in front of a diner and watched through the window people eating cheeseburgers and French fries and talking gigantically. All these people, I looked at them as if they were speaking Mandarin or discussing string theory, with their ease around their food and their ease around their bodies and their ability to live their lives without the doubt and self-loathing that brings me to my arthritic knees still. There’s no such thing as magic, Taffy. I shook my head at the impossibility of it all, and sitting here writing this, I still do.

Taffy Brodesser-Akner is a contributing writer for the magazine. In September, she will become a features writer for The Times’s culture desk and a staff writer for the magazine.

Primary Care Best Practice

This post is about two important articles related to Primary Care Best Practice: One by Atul Gawande called “Big Med” and the other from Harvard Medical School about Physician Burnout.

As usual, Atul tells stories. His stories begin with his positive experience at the Cheesecake Factory and with his mother’s knee replacement surgery.

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Article by Atul Gawande Big Med and the Cheesecake Factory
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JCR NOTES

Article explores the potential for transferring some of the operational excellence of the Cheesecake Factory to aspects of health care.

He finds it tempting to look for 95% standardization and 5% customization.
He sees lessons in rolling out innovations through test kitchens and training that includes how to train others.
He sees heroes in doctors that push to articulate a standard of care, or technology, or equipment, or pharmaceutical.

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CREDIT: New Yorker Article by Atul Gawande “Big Med”

Annals of Health Care
August 13, 2012 Issue
Big Med
Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?

By Atul Gawande

Medicine has long resisted the productivity revolutions that transformed other industries. But the new chains aim to change this.Illustration by Harry Campbell

It was Saturday night, and I was at the local Cheesecake Factory with my two teen-age daughters and three of their friends. You may know the chain: a hundred and sixty restaurants with a catalogue-like menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the “Skinnylicious” menu), plus a hundred and twenty-four choices of beverage. It’s a linen-napkin-and-tablecloth sort of place, but with something for everyone. There’s wine and wasabi-crusted ahi tuna, but there’s also buffalo wings and Bud Light. The kids ordered mostly comfort food—pot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza, pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon.

The place is huge, but it’s invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.
The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.
I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

It’s easy to mock places like the Cheesecake Factory—restaurants that have brought chain production to complicated sit-down meals. But the “casual dining sector,” as it is known, plays a central role in the ecosystem of eating, providing three-course, fork-and-knife restaurant meals that most people across the country couldn’t previously find or afford. The ideas start out in élite, upscale restaurants in major cities. You could think of them as research restaurants, akin to research hospitals. Some of their enthusiasms—miso salmon, Chianti-braised short ribs, flourless chocolate espresso cake—spread to other high-end restaurants. Then the casual-dining chains reëngineer them for affordable delivery to millions. Does health care need something like this?

Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake Factory’s major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt.

Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They’ve decided to become employees, and health systems have become chains.

I’m no exception. I am an employee of an academic, nonprofit health system called Partners HealthCare, which owns the Brigham and Women’s Hospital and the Massachusetts General Hospital, along with seven other hospitals, and is affiliated with dozens of clinics around eastern Massachusetts. Partners has sixty thousand employees, including six thousand doctors. Our competitors include CareGroup, a system of five regional hospitals, and a new for-profit chain called the Steward Health Care System.

Steward was launched in late 2010, when Cerberus—the multibillion-dollar private-investment firm—bought a group of six failing Catholic hospitals in the Boston area for nine hundred million dollars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses.

Cerberus has owned controlling stakes in Chrysler and gmac Financing and currently has stakes in Albertsons grocery stories, one of Austria’s largest retail bank chains, and the Freedom Group, which it built into one of the biggest gun-and-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw another opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south Florida. It’s trying to create what some have called the Southwest Airlines of health care—a network of high-quality hospitals that would appeal to a more cost-conscious public.

Steward’s aggressive growth has made local doctors like me nervous. But many health systems, for-profit and not-for-profit, share its goal: large-scale, production-line medicine. The way medical care is organized is changing—because the way we pay for it is changing.
Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens. The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.

Health-care reforms—public and private—have sought to reshape that system. This year, my employer’s new contracts with Medicare, BlueCross BlueShield, and others link financial reward to clinical performance. The more the hospital exceeds its cost-reduction and quality-improvement targets, the more money it can keep. If it misses the targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it’s their business, too.

The theory the country is about to test is that chains will make us better and more efficient. The question is how. To most of us who work in health care, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine can’t be reduced to a recipe.

Then again neither can good food: every dish involves attention to detail and individual adjustments that require human judgment. Yet, some chains manage to achieve good, consistent results thousands of times a day across the entire country. I decided to get inside one and find out how they did it.

Dave Luz is the regional manager for the eight Cheesecake Factories in the Boston area. He oversees operations that bring in eighty million dollars in yearly revenue, about as much as a medium-sized hospital. Luz (rhymes with “fuzz”) is forty-seven, and had started out in his twenties waiting tables at a Cheesecake Factory restaurant in Los Angeles. He was writing screenplays, but couldn’t make a living at it. When he and his wife hit thirty and had their second child, they came back east to Boston to be closer to family. He decided to stick with the Cheesecake Factory. Luz rose steadily, and made a nice living. “I wanted to have some business skills,” he said—he started a film-production company on the side—“and there was no other place I knew where you could go in, know nothing, and learn top to bottom how to run a business.”

To show me how a Cheesecake Factory works, he took me into the kitchen of his busiest restaurant, at Prudential Center, a shopping and convention hub. The kitchen design is the same in every restaurant, he explained. It’s laid out like a manufacturing facility, in which raw materials in the back of the plant come together as a finished product that rolls out the front. Along the back wall are the walk-in refrigerators and prep stations, where half a dozen people stood chopping and stirring and mixing. The next zone is where the cooking gets done—two parallel lines of countertop, forty-some feet long and just three shoe-lengths apart, with fifteen people pivoting in place between the stovetops and grills on the hot side and the neatly laid-out bins of fixings (sauces, garnishes, seasonings, and the like) on the cold side. The prep staff stock the pullout drawers beneath the counters with slabs of marinated meat and fish, serving-size baggies of pasta and crabmeat, steaming bowls of brown rice and mashed potatoes. Basically, the prep crew handles the parts, and the cooks do the assembly.

Computer monitors positioned head-high every few feet flashed the orders for a given station. Luz showed me the touch-screen tabs for the recipe for each order and a photo showing the proper presentation. The recipe has the ingredients on the left part of the screen and the steps on the right. A timer counts down to a target time for completion. The background turns from green to yellow as the order nears the target time and to red when it has exceeded it.

I watched Mauricio Gaviria at the broiler station as the lunch crowd began coming in. Mauricio was twenty-nine years old and had worked there eight years. He’d got his start doing simple prep—chopping vegetables—and worked his way up to fry cook, the pasta station, and now the sauté and broiler stations. He bounced in place waiting for the pace to pick up. An order for a “hibachi” steak popped up. He tapped the screen to open the order: medium-rare, no special requests. A ten-minute timer began. He tonged a fat hanger steak soaking in teriyaki sauce onto the broiler and started a nest of sliced onions cooking beside it. While the meat was grilling, other orders arrived: a Kobe burger, a blue-cheese B.L.T. burger, three “old-fashioned” burgers, five veggie burgers, a “farmhouse” burger, and two Thai chicken wraps. Tap, tap, tap. He got each of them grilling.

I brought up the hibachi-steak recipe on the screen. There were instructions to season the steak, sauté the onions, grill some mushrooms, slice the meat, place it on the bed of onions, pile the mushrooms on top, garnish with parsley and sesame seeds, heap a stack of asparagus tempura next to it, shape a tower of mashed potatoes alongside, drop a pat of wasabi butter on top, and serve.

Two things struck me. First, the instructions were precise about the ingredients and the objectives (the steak slices were to be a quarter of an inch thick, the presentation just so), but not about how to get there. The cook has to decide how much to salt and baste, how to sequence the onions and mushrooms and meat so they’re done at the same time, how to swivel from grill to countertop and back, sprinkling a pinch of salt here, flipping a burger there, sending word to the fry cook for the asparagus tempura, all the while keeping an eye on the steak. In producing complicated food, there might be recipes, but there was also a substantial amount of what’s called “tacit knowledge”—knowledge that has not been reduced to instructions.

Second, Mauricio never looked at the instructions anyway. By the time I’d finished reading the steak recipe, he was done with the dish and had plated half a dozen others. “Do you use this recipe screen?” I asked.

“No. I have the recipes right here,” he said, pointing to his baseball-capped head.

He put the steak dish under warming lights, and tapped the screen to signal the servers for pickup. But before the dish was taken away, the kitchen manager stopped to look, and the system started to become clearer. He pulled a clean fork out and poked at the steak. Then he called to Mauricio and the two other cooks manning the grill station.

“Gentlemen,” he said, “this steak is perfect.” It was juicy and pink in the center, he said. “The grill marks are excellent.” The sesame seeds and garnish were ample without being excessive. “But the tower is too tight.” I could see what he meant. The mashed potatoes looked a bit like something a kid at the beach might have molded with a bucket. You don’t want the food to look manufactured, he explained. Mauricio fluffed up the potatoes with a fork.

I watched the kitchen manager for a while. At every Cheesecake Factory restaurant, a kitchen manager is stationed at the counter where the food comes off the line, and he rates the food on a scale of one to ten. A nine is near-perfect. An eight requires one or two corrections before going out to a guest. A seven needs three. A six is unacceptable and has to be redone. This inspection process seemed a tricky task. No one likes to be second-guessed. The kitchen manager prodded gently, being careful to praise as often as he corrected. (“Beautiful. Beautiful!” “The pattern of this pesto glaze is just right.”) But he didn’t hesitate to correct.

“We’re getting sloppy with the plating,” he told the pasta station. He was unhappy with how the fry cooks were slicing the avocado spring rolls. “Gentlemen, a half-inch border on this next time.” He tried to be a coach more than a policeman. “Is this three-quarters of an ounce of Parm-Romano?”

And that seemed to be the spirit in which the line cooks took him and the other managers. The managers had all risen through the ranks. This earned them a certain amount of respect. They in turn seemed respectful of the cooks’ skills and experience. Still, the oversight is tight, and this seemed crucial to the success of the enterprise.

The managers monitored the pace, too—scanning the screens for a station stacking up red flags, indicating orders past the target time, and deciding whether to give the cooks at the station a nudge or an extra pair of hands. They watched for waste—wasted food, wasted time, wasted effort. The formula was Business 101: Use the right amount of goods and labor to deliver what customers want and no more. Anything more is waste, and waste is lost profit.

I spoke to David Gordon, the company’s chief operating officer. He told me that the Cheesecake Factory has worked out a staff-to-customer ratio that keeps everyone busy but not so busy that there’s no slack in the system in the event of a sudden surge of customers. More difficult is the problem of wasted food. Although the company buys in bulk from regional suppliers, groceries are the biggest expense after labor, and the most unpredictable. Everything—the chicken, the beef, the lettuce, the eggs, and all the rest—has a shelf life. If a restaurant were to stock too much, it could end up throwing away hundreds of thousands of dollars’ worth of food. If a restaurant stocks too little, it will have to tell customers that their favorite dish is not available, and they may never come back. Groceries, Gordon said, can kill a restaurant.

The company’s target last year was at least 97.5-per-cent efficiency: the managers aimed at throwing away no more than 2.5 per cent of the groceries they bought, without running out. This seemed to me an absurd target. Achieving it would require knowing in advance almost exactly how many customers would be coming in and what they were going to want, then insuring that the cooks didn’t spill or toss or waste anything. Yet this is precisely what the organization has learned to do. The chain-restaurant industry has produced a field of computer analytics known as “guest forecasting.”

“We have forecasting models based on historical data—the trend of the past six weeks and also the trend of the previous year,” Gordon told me. “The predictability of the business has become astounding.” The company has even learned how to make adjustments for the weather or for scheduled events like playoff games that keep people at home.

A computer program known as Net Chef showed Luz that for this one restaurant food costs accounted for 28.73 per cent of expenses the previous week. It also showed exactly how many chicken breasts were ordered that week ($1,614 worth), the volume sold, the volume on hand, and how much of last week’s order had been wasted (three dollars’ worth). Chain production requires control, and they’d figured out how to achieve it on a mass scale.

As a doctor, I found such control alien—possibly from a hostile planet. We don’t have patient forecasting in my office, push-button waste monitoring, or such stringent, hour-by-hour oversight of the work we do, and we don’t want to. I asked Luz if he had ever thought about the contrast when he went to see a doctor. We were standing amid the bustle of the kitchen, and the look on his face shifted before he answered.
“I have,” he said. His mother was seventy-eight. She had early Alzheimer’s disease, and required a caretaker at home. Getting her adequate medical care was, he said, a constant battle.

Recently, she’d had a fall, apparently after fainting, and was taken to a local emergency room. The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. Luz understood that sometimes explanations prove elusive. But the clinicians didn’t seem to be following any coördinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told Luz the results.

A nurse came at ten the next morning and said that his mother was being discharged. But his mother’s nurse was on break, and the discharge paperwork with her instructions and prescriptions hadn’t been done. So they waited. Then the next person they needed was at lunch. It was as if the clinicians were the customers, and the patients’ job was to serve them. “We didn’t get to go until 6 p.m., with a tired, disabled lady and a long drive home.” Even then she still had to be changed out of her hospital gown and dressed. Luz pressed the call button to ask for help. No answer. He went out to the ward desk.

The aide was on break, the secretary said. “Don’t you dress her yourself at home?” He explained that he didn’t, and made a fuss.

An aide was sent. She was short with him and rough in changing his mother’s clothes. “She was manhandling her,” Luz said. “I felt like, ‘Stop. I’m not one to complain. I respect what you do enormously. But if there were a video camera in here, you’d be on the evening news.’ I sent her out. I had to do everything myself. I’m stuffing my mom’s boob in her bra. It was unbelievable.”

His mother was given instructions to check with her doctor for the results of cultures taken during her stay, for a possible urinary-tract infection. But when Luz tried to follow up, he couldn’t get through to her doctor for days. “Doctors are busy,” he said. “I get it. But come on.” An office assistant finally told him that the results wouldn’t be ready for another week and that she was to see a neurologist. No explanations. No chance to ask questions.

The neurologist, after giving her a two-minute exam, suggested tests that had already been done and wrote a prescription that he admitted was of doubtful benefit. Luz’s family seemed to encounter this kind of disorganization, imprecision, and waste wherever his mother went for help.

“It is unbelievable to me that they would not manage this better,” Luz said. I asked him what he would do if he were the manager of a neurology unit or a cardiology clinic. “I don’t know anything about medicine,” he said. But when I pressed he thought for a moment, and said, “This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

This is not at all the normal way of doing things in medicine. (“You’re scaring me,” he said, when I told him.) But it’s exactly what the new health-care chains are now hoping to do on a mass scale. They want to create Cheesecake Factories for health care. The question is whether the medical counterparts to Mauricio at the broiler station—the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. Fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the “best practices” are?

In March, my mother underwent a total knee replacement, like at least six hundred thousand Americans each year. She’d had a partial knee replacement a decade ago, when arthritis had worn away part of the cartilage, and for a while this served her beautifully. The surgeon warned, however, that the results would be temporary, and about five years ago the pain returned.

She’s originally from Ahmadabad, India, and has spent three decades as a pediatrician, attending to the children of my small Ohio home town. She’s chatty. She can’t go through a grocery checkout line or get pulled over for speeding without learning people’s names and a little bit about them. But she didn’t talk about her mounting pain. I noticed, however, that she had developed a pronounced limp and had become unable to walk even moderate distances. When I asked her about it, she admitted that just getting out of bed in the morning was an ordeal. Her doctor showed me her X-rays. Her partial prosthesis had worn through the bone on the lower surface of her knee. It was time for a total knee replacement.
This past winter, she finally stopped putting it off, and asked me to find her a surgeon. I wanted her to be treated well, in both the technical and the human sense. I wanted a place where everyone and everything—from the clinic secretary to the physical therapists—worked together seamlessly.

My mother planned to come to Boston, where I live, for the surgery so she could stay with me during her recovery. (My father died last year.) Boston has three hospitals in the top rank of orthopedic surgery. But even a doctor doesn’t have much to go on when it comes to making a choice. A place may have a great reputation, but it’s hard to know about actual quality of care.

Unlike some countries, the United States doesn’t have a monitoring system that tracks joint-replacement statistics. Even within an institution, I found, surgeons take strikingly different approaches. They use different makes of artificial joints, different kinds of anesthesia, different regimens for post-surgical pain control and physical therapy.

In the absence of information, I went with my own hospital, the Brigham and Women’s Hospital. Our big-name orthopedic surgeons treat Olympians and professional athletes. Nine of them do knee replacements. Of most interest to me, however, was a surgeon who was not one of the famous names. He has no national recognition. But he has led what is now a decade-long experiment in standardizing joint-replacement surgery.

John Wright is a New Zealander in his late fifties. He’s a tower crane of a man, six feet four inches tall, and so bald he barely seems to have eyebrows. He’s informal in attire—I don’t think I’ve ever seen him in a tie, and he is as apt to do rounds in his zip-up anorak as in his white coat—but he exudes competence.

“Customization should be five per cent, not ninety-five per cent, of what we do,” he told me. A few years ago, he gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did what Luz considered the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit.

They came up with a plan for anesthesia based on research studies—including giving certain pain medications before the patient entered the operating room and using spinal anesthesia plus an injection of local anesthetic to block the main nerve to the knee. They settled on a postoperative regimen, too. The day after a knee replacement, most orthopedic surgeons have their patients use a continuous passive-motion machine, which flexes and extends the knee as they lie in bed. Large-scale studies, though, have suggested that the machines don’t do much good. Sure enough, when the members of Wright’s group examined their own patients, they found that the ones without the machine got out of bed sooner after surgery, used less pain medication, and had more range of motion at discharge. So Wright instructed the hospital to get rid of the machines, and to use the money this saved (ninety thousand dollars a year) to pay for more physical therapy, something that is proven to help patient mobility. Therapy, starting the day after surgery, would increase from once to twice a day, including weekends.

Even more startling, Wright had persuaded the surgeons to accept changes in the operation itself; there was now, for instance, a limit as to which prostheses they could use. Each of our nine knee-replacement surgeons had his preferred type and brand. Knee surgeons are as particular about their implants as professional tennis players are about their racquets. But the hardware is easily the biggest cost of the operation—the average retail price is around eight thousand dollars, and some cost twice that, with no solid evidence of real differences in results.

Knee implants were largely perfected a quarter century ago. By the nineteen-nineties, studies showed that, for some ninety-five per cent of patients, the implants worked magnificently a decade after surgery. Evidence from the Australian registry has shown that not a single new knee or hip prosthesis had a lower failure rate than that of the established prostheses. Indeed, thirty per cent of the new models were likelier to fail. Like others on staff, Wright has advised companies on implant design. He believes that innovation will lead to better implants. In the meantime, however, he has sought to limit the staff to the three lowest-cost knee implants.

These have been hard changes for many people to accept. Wright has tried to figure out how to persuade clinicians to follow the standardized plan. To prevent revolt, he learned, he had to let them deviate at times from the default option. Surgeons could still order a passive-motion machine or a preferred prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter the treatment orders in the computer themselves. To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low.

I asked one of his orthopedic colleagues, a surgeon named John Ready, what he thought about Wright’s efforts. Ready was philosophical. He recognized that the changes were improvements, and liked most of them. But he wasn’t happy when Wright told him that his knee-implant manufacturer wasn’t matching the others’ prices and would have to be dropped.

“It’s not ideal to lose my prosthesis,” Ready said. “I could make the switch. The differences between manufacturers are minor. But there’d be a learning curve.” Each implant has its quirks—how you seat it, what tools you use. “It’s probably a ten-case learning curve for me.” Wright suggested that he explain the situation to the manufacturer’s sales rep. “I’m my rep’s livelihood,” Ready said. “He probably makes five hundred dollars a case from me.” Ready spoke to his rep. The price was dropped.

Wright has become the hospital’s kitchen manager—not always a pleasant role. He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).

My mother was one of the beneficiaries. She had insisted to Dr. Wright that she would need a week in the hospital after the operation and three weeks in a rehabilitation center. That was what she’d required for her previous knee operation, and this one was more extensive.
“We’ll see,” he told her.

The morning after her operation, he came in and told her that he wanted her getting out of bed, standing up, and doing a specific set of exercises he showed her. “He’s pushy, if you want to say it that way,” she told me. The physical therapists and nurses were, too. They were a team, and that was no small matter. I counted sixty-three different people involved in her care. Nineteen were doctors, including the surgeon and chief resident who assisted him, the anesthesiologists, the radiologists who reviewed her imaging scans, and the junior residents who examined her twice a day and adjusted her fluids and medications. Twenty-three were nurses, including her operating-room nurses, her recovery-room nurse, and the many ward nurses on their eight-to-twelve-hour shifts. There were also at least five physical therapists; sixteen patient-care assistants, helping check her vital signs, bathe her, and get her to the bathroom; plus X-ray and EKG technologists, transport workers, nurse practitioners, and physician assistants. I didn’t even count the bioengineers who serviced the equipment used, the pharmacists who dispensed her medications, or the kitchen staff preparing her food while taking into account her dietary limitations. They all had to coördinate their contributions, and they did.

Three days after her operation, she was getting in and out of bed on her own. She was on virtually no narcotic medication. She was starting to climb stairs. Her knee pain was actually less than before her operation. She left the hospital for the rehabilitation center that afternoon.

The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results. My mother experienced what happens in medicine when someone takes charge. Of course, John Wright isn’t alone in trying to design and implement this kind of systematic care, in joint surgery and beyond. The Virginia Mason Medical Center, in Seattle, has done it for knee surgery and cancer care; the Geisinger Health Center, in Pennsylvania, has done it for cardiac surgery and primary care; the University of Michigan Health System standardized how its doctors give blood transfusions to patients, reducing the need for transfusions by thirty-one per cent and expenses by two hundred thousand dollars a month. Yet, unless such programs are ramped up on a nationwide scale, they aren’t going to do much to improve health care for most people or reduce the explosive growth of health-care costs.

In medicine, good ideas still take an appallingly long time to trickle down. Recently, the American Academy of Neurology and the American Headache Society released new guidelines for migraine-headache-treatment. They recommended treating severe migraine sufferers—who have more than six attacks a month—with preventive medications and listed several drugs that markedly reduce the occurrence of attacks. The authors noted, however, that previous guidelines going back more than a decade had recommended such remedies, and doctors were still not providing them to more than two-thirds of patients. One study examined how long it took several major discoveries, such as the finding that the use of beta-blockers after a heart attack improves survival, to reach even half of Americans. The answer was, on average, more than fifteen years.

Scaling good ideas has been one of our deepest problems in medicine. Regulation has had its place, but it has proved no more likely to produce great medicine than food inspectors are to produce great food. During the era of managed care, insurance-company reviewers did hardly any better. We’ve been stuck. But do we have to be?

Every six months, the Cheesecake Factory puts out a new menu. This means that everyone who works in its restaurants expects to learn something new twice a year. The March, 2012, Cheesecake Factory menu included thirteen new items. The teaching process is now finely honed: from start to finish, rollout takes just seven weeks.

The ideas for a new dish, or for tweaking an old one, can come from anywhere. One of the Boston prep cooks told me about an idea he once had that ended up in a recipe. David Overton, the founder and C.E.O. of the Cheesecake Factory, spends much of his time sampling a range of cuisines and comes up with many dishes himself. All the ideas, however, go through half a dozen chefs in the company’s test kitchen, in Calabasas. They figure out how to make each recipe reproducible, appealing, and affordable. Then they teach the new recipe to the company’s regional managers and kitchen managers.

Dave Luz, the Boston regional manager, went to California for training this past January with his chief kitchen manager, Tom Schmidt, a chef with fifteen years’ experience. They attended lectures, watched videos, participated in workshops. It sounded like a surgical conference. Where I might be taught a new surgical technique, they were taught the steps involved in preparing a “Santorini farro salad.” But there was a crucial difference. The Cheesecake instructors also trained the attendees how to teach what they were learning. In medicine, we hardly ever think about how to implement what we’ve learned. We learn what we want to, when we want to.

On the first training day, the kitchen managers worked their way through thirteen stations, preparing each new dish, and their performances were evaluated. The following day, they had to teach their regional managers how to prepare each dish—Schmidt taught Luz—and this time the instructors assessed how well the kitchen managers had taught.
The managers returned home to replicate the training session for the general manager and the chief kitchen manager of every restaurant in their region. The training at the Boston Prudential Center restaurant took place on two mornings, before the lunch rush. The first day, the managers taught the kitchen staff the new menu items. There was a lot of poring over the recipes and videos and fussing over the details. The second day, the cooks made the new dishes for the servers. This gave the cooks some practice preparing the food at speed, while allowing the servers to learn the new menu items. The dishes would go live in two weeks. I asked a couple of the line cooks how long it took them to learn to make the new food.

“I know it already,” one said.
“I make it two times, and that’s all I need,” the other said.
Come on, I said. How long before they had it down pat?
“One day,” they insisted. “It’s easy.”

I asked Schmidt how much time he thought the cooks required to master the recipes. They thought a day, I told him. He grinned. “More like a month,” he said.

Even a month would be enviable in medicine, where innovations commonly spread at a glacial pace. The new health-care chains, though, are betting that they can change that, in much the same way that other chains have.
Armin Ernst is responsible for intensive-care-unit operations in Steward’s ten hospitals. The I.C.U.s he oversees serve some eight thousand patients a year. In another era, an I.C.U. manager would have been a facilities expert. He would have spent his time making sure that the equipment, electronics, pharmacy resources, and nurse staffing were up to snuff. He would have regarded the I.C.U. as the doctors’ workshop, and he would have wanted to give them the best possible conditions to do their work as they saw fit.
Ernst, though, is a doctor—a new kind of doctor, whose goal is to help disseminate good ideas. He doesn’t see the I.C.U. as a doctors’ workshop. He sees it as the temporary home of the sickest, most fragile people in the country. Nowhere in health care do we expend more resources. Although fewer than one in four thousand Americans are in intensive care at any given time, they account for four per cent of national health-care costs. Ernst believes that his job is to make sure that everyone is collaborating to provide the most effective and least wasteful care possible.

He looked like a regular doctor to me. Ernst is fifty years old, a native German who received his medical degree at the University of Heidelberg before training in pulmonary and critical-care medicine in the United States. He wears a white hospital coat and talks about drips and ventilator settings, like any other critical-care specialist. But he doesn’t deal with patients: he deals with the people who deal with patients.

Ernst says he’s not telling clinicians what to do. Instead, he’s trying to get clinicians to agree on precise standards of care, and then make sure that they follow through on them. (The word “consensus” comes up a lot.) What I didn’t understand was how he could enforce such standards in ten hospitals across three thousand square miles.

Late one Friday evening, I joined an intensive-care-unit team on night duty. But this team was nowhere near a hospital. We were in a drab one-story building behind a meat-trucking facility outside of Boston, in a back section that Ernst called his I.C.U. command center. It was outfitted with millions of dollars’ worth of technology. Banks of computer screens carried a live feed of cardiac-monitor readings, radiology-imaging scans, and laboratory results from I.C.U. patients throughout Steward’s hospitals. Software monitored the stream and produced yellow and red alerts when it detected patterns that raised concerns. Doctors and nurses manned consoles where they could toggle on high-definition video cameras that allowed them to zoom into any I.C.U. room and talk directly to the staff on the scene or to the patients themselves.

The command center was just a few months old. The team had gone live in only four of the ten hospitals. But in the next several months Ernst’s “tele-I.C.U.” team will have the ability to monitor the care for every patient in every I.C.U. bed in the Steward health-care system.
A doctor, two nurses, and an administrative assistant were on duty in the command center each night I visited. Christina Monti was one of the nurses. A pixie-like thirty-year-old with nine years’ experience as a cardiac intensive-care nurse, she was covering Holy Family Hospital, on the New Hampshire border, and St. Elizabeth’s Medical Center, in Boston’s Brighton neighborhood. When I sat down with her, she was making her rounds, virtually.

First, she checked on the patients she had marked as most critical. She reviewed their most recent laboratory results, clinical notes, and medication changes in the electronic record. Then she made a “visit,” flicking on the two-way camera and audio system. If the patients were able to interact, she would say hello to them in their beds. She asked the staff members whether she could do anything for them. The tele-I.C.U. team provided the staff with extra eyes and ears when needed. If a crashing patient diverts the staff’s attention, the members of the remote team can keep an eye on the other patients. They can handle computer paperwork if a nurse falls behind; they can look up needed clinical information. The hospital staff have an OnStar-like button in every room that they can push to summon the tele-I.C.U. team.

Monti also ran through a series of checks for each patient. She had a reference list of the standards that Ernst had negotiated with the people running the I.C.U.s, and she looked to see if they were being followed. The standards covered basics, from hand hygiene to measures for stomach-ulcer prevention. In every room with a patient on a respirator, for instance, Monti made sure the nurse had propped the head of the bed up at least thirty degrees, which makes pneumonia less likely. She made sure the breathing tube in the patient’s mouth was secure, to reduce the risk of the tube’s falling out or becoming disconnected. She zoomed in on the medication pumps to check that the drips were dosed properly. She was not looking for bad nurses or bad doctors. She was looking for the kinds of misses that even excellent nurses and doctors can make under pressure.
The concept of the remote I.C.U. started with an effort to let specialists in critical-care medicine, who are in short supply, cover not just one but several community hospitals. Two hundred and fifty hospitals from Alaska to Virginia have installed a version of the tele-I.C.U. It produced significant improvements in outcomes and costs—and, some discovered, a means of driving better practices even in hospitals that had specialists on hand.
After five minutes of observation, however, I realized that the remote I.C.U. team wasn’t exactly in command; it was in negotiation. I observed Monti perform a video check on a middle-aged man who had just come out of heart surgery. A soft chime let the people in the room know she was dropping in. The man was unconscious, supported by a respirator and intravenous drips. At his bedside was a nurse hanging a bag of fluid. She seemed to stiffen at the chime’s sound.

“Hi,” Monti said to her. “I’m Chris. Just making my evening rounds. How are you?” The bedside nurse gave the screen only a sidelong glance.
Ernst wasn’t oblivious of the issue. He had taken pains to introduce the command center’s team, spending weeks visiting the units and bringing doctors and nurses out to tour the tele-I.C.U. before a camera was ever turned on. But there was no escaping the fact that these were strangers peering over the staff’s shoulders. The bedside nurse’s chilliness wasn’t hard to understand.

In a single hour, however, Monti had caught a number of problems. She noticed, for example, that a patient’s breathing tube had come loose. Another patient wasn’t getting recommended medication to prevent potentially fatal blood clots. Red alerts flashed on the screen—a patient with an abnormal potassium level that could cause heart-rhythm problems, another with a sudden leap in heart rate.

Monti made sure that the team wasn’t already on the case and that the alerts weren’t false alarms. Checking the computer, she figured out that a doctor had already ordered a potassium infusion for the woman with the low level. Flipping on a camera, she saw that the patient with the high heart rate was just experiencing the stress of being helped out of bed for the first time after surgery. But the unsecured breathing tube and the forgotten blood-clot medication proved to be oversights. Monti raised the concerns with the bedside staff.

Sometimes they resist. “You have got to be careful from patient to patient,” Gerard Hayes, the tele-I.C.U. doctor on duty, explained. “Pushing hard on one has ramifications for how it goes with a lot of patients. You don’t want to sour whole teams on the tele-I.C.U.” Across the country, several hospitals have decommissioned their systems. Clinicians have been known to place a gown over the camera, or even rip the camera out of the wall. Remote monitoring will never be the same as being at the bedside. One nurse called the command center to ask the team not to turn on the video system in her patient’s room: he was delirious and confused, and the sudden appearance of someone talking to him from the television would freak him out.
Still, you could see signs of change. I watched Hayes make his virtual rounds through the I.C.U. at St. Anne’s Hospital, in Fall River, near the Rhode Island border. He didn’t yet know all the members of the hospital staff—this was only his second night in the command center, and when he sees patients in person it’s at a hospital sixty miles north. So, in his dealings with the on-site clinicians, he was feeling his way.

Checking on one patient, he found a few problems. Mr. Karlage, as I’ll call him, was in his mid-fifties, an alcoholic smoker with cirrhosis of the liver, severe emphysema, terrible nutrition, and now a pneumonia that had put him into respiratory failure. The I.C.U. team injected him with antibiotics and sedatives, put a breathing tube down his throat, and forced pure oxygen into his lungs. Over a few hours, he stabilized, and the I.C.U. doctor was able to turn his attention to other patients.

But stabilizing a sick patient is like putting out a house fire. There can be smoldering embers just waiting to reignite. Hayes spotted a few. The ventilator remained set to push breaths at near-maximum pressure, and, given the patient’s severe emphysema, this risked causing a blowout. The oxygen concentration was still cranked up to a hundred per cent, which, over time, can damage the lungs. The team had also started several broad-spectrum antibiotics all at once, and this regimen had to be dialled back if they were to avoid breeding resistant bacteria.

Hayes had to notify the unit doctor. An earlier interaction, however, had not been promising. During a video check on a patient, Hayes had introduced himself and mentioned an issue he’d noticed. The unit doctor stared at him with folded arms, mouth shut tight. Hayes was a former Navy flight surgeon with twenty years’ experience as an I.C.U. doctor and looked to have at least a decade on the St. Anne’s doctor. But the doctor was no greenhorn, either, and gave him the brushoff: “The morning team can deal with that.” Now Hayes needed to call him about Mr. Karlage. He decided to do it by phone.

“Sounds like you’re having a busy night,” Hayes began when he reached the doctor. “Mr. Karlage is really turning around, huh?” Hayes praised the doctor’s work. Then he brought up his three issues, explaining what he thought could be done and why. He spoke like a consultant brought in to help. This went over better. The doctor seemed to accept Hayes’s suggestions.

Unlike a mere consultant, however, Hayes took a few extra steps to make sure his suggestions were carried out. He spoke to the nurse and the respiratory therapist by video and explained the changes needed. To carry out the plan, they needed written orders from the unit doctor. Hayes told them to call him back if they didn’t get the orders soon.

Half an hour later, Hayes called Mr. Karlage’s nurse again. She hadn’t received the orders. For all the millions of dollars of technology spent on the I.C.U. command center, this is where the plug meets the socket. The fundamental question in medicine is: Who is in charge? With the opening of the command center, Steward was trying to change the answer—it gave the remote doctors the authority to issue orders as well. The idea was that they could help when a unit doctor got too busy and fell behind, and that’s what Hayes chose to believe had happened. He entered the orders into the computer. In a conflict, however, the on-site physician has the final say. So Hayes texted the St. Anne’s doctor, informing him of the changes and asking if he’d let him know if he disagreed.

Hayes received no reply. No “thanks” or “got it” or “O.K.” After midnight, though, the unit doctor pressed the video call button and his face flashed onto Hayes’s screen. Hayes braced for a confrontation. Instead, the doctor said, “So I’ve got this other patient and I wanted to get your opinion.”
Hayes suppressed a smile. “Sure,” he said.

When he signed off, he seemed ready to high-five someone. “He called us,” he marvelled. The command center was gaining credibility.
Armin Ernst has big plans for the command center—a rollout of full-scale treatment protocols for patients with severe sepsis, acute respiratory-distress syndrome, and other conditions; strategies to reduce unnecessary costs; perhaps even computer forecasting of patient volume someday. Steward is already extending the command-center concept to in-patient psychiatry. Emergency rooms and surgery may be next. Other health systems are pursuing similar models. The command-center concept provides the possibility of, well, command.

Today, some ninety “super-regional” health-care systems have formed across the country—large, growing chains of clinics, hospitals, and home-care agencies. Most are not-for-profit. Financial analysts expect the successful ones to drive independent medical centers out of existence in much of the country—either by buying them up or by drawing away their patients with better quality and cost control. Some small clinics and stand-alone hospitals will undoubtedly remain successful, perhaps catering to the luxury end of health care the way gourmet restaurants do for food. But analysts expect that most of us will gravitate to the big systems, just as we have moved away from small pharmacies to CVS and Walmart.
Already, there have been startling changes. Cleveland Clinic, for example, opened nine regional hospitals in northeast Ohio, as well as health centers in southern Florida, Toronto, and Las Vegas, and is now going international, with a three-hundred-and-sixty-four-bed hospital in Abu Dhabi scheduled to open next year. It reached an agreement with Lowe’s, the home-improvement chain, guaranteeing a fixed price for cardiac surgery for the company’s employees and dependents. The prospect of getting better care for a lower price persuaded Lowe’s to cover all out-of-pocket costs for its insured workers to go to Cleveland, including co-payments, airfare, transportation, and lodging. Three other companies, including Kohl’s department stores, have made similar deals, and a dozen more, including Boeing, are in negotiations.

Big Medicine is on the way.
Reinventing medical care could produce hundreds of innovations. Some may be as simple as giving patients greater e-mail and online support from their clinicians, which would enable timelier advice and reduce the need for emergency-room visits. Others might involve smartphone apps for coaching the chronically ill in the management of their disease, new methods for getting advice from specialists, sophisticated systems for tracking outcomes and costs, and instant delivery to medical teams of up-to-date care protocols. Innovations could take a system that requires sixty-three clinicians for a knee replacement and knock the number down by half or more. But most significant will be the changes that finally put people like John Wright and Armin Ernst in charge of making care coherent, coördinated, and affordable. Essentially, we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring.

Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them.
A new generation of medical leaders and institutions professes to have a different aim. But a lesson of the past century is that government can influence the behavior of big corporations, by requiring transparency about their performance and costs, and by enacting rules and limitations to protect the ordinary citizen. The federal government has broken up monopolies like Standard Oil and A.T. & T.; in some parts of the country, similar concerns could develop in health care.

Mixed feelings about the transformation are unavoidable. There’s not just the worry about what Big Medicine will do; there’s also the worry about how society and government will respond. For the changes to live up to our hopes—lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.

The vast savings of Big Medicine could be widely shared—or reserved for a few. The clinicians who are trying to reinvent medicine aren’t doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates—and that won’t be automatic.

Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?

Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.”

And we are seeing glimpses of this change. In my mother’s rehabilitation center, miles away from where her surgery was done, the physical therapists adhered to the exercise protocols that Dr. Wright’s knee factory had developed. He didn’t have a video command center, so he came out every other day to check on all the patients and make sure that the staff was following the program. My mother was sure she’d need a month in rehab, but she left in just a week, incurring a fraction of the costs she would have otherwise. She walked out the door using a cane. On her first day at home with me, she climbed two flights of stairs and walked around the block for exercise.

The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be. ♦

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Article on Physician Burnout and Best Practice
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JCR Notes:

A primary care physician’s work includes vaccinations, screenings, chronic disease prevention and treatment, relationship building, family planning, behavioral health, counseling, and other vital but time-consuming work.

To be in full compliance with the U.S. Preventive Services Task Force recommendations, primary care physicians with average-sized patient populations need to dedicate 7.4 hours per day to preventative care alone. Taken in conjunction with the other primary care services, namely acute and chronic care, the estimated total working hours per primary care physician comes to 21.7 hours per day, or 108.5 hours per week.

“Complete Care” across 8500 physicians and 4.4 million members at SCPMG has four elements:

1. Share accountability:
share accountability for preventative and chronic care services (e.g., treating people with hypertension or women in need of a mammogram) with high-volume specialties.

2. Delegation:
One fundamental move was to transfer tasks from physicians — not just those in primary care — to non-physicians

3. Information technology
“Outreach team” manages information technologies that allowed patients to schedule visits from mobile apps, access online personalized health care plans (e.g., customized weight-loss calendars and healthy recipes), and manage complex schedules (e.g., the steps prior to a kidney transplant).

4. Standardized Care Process (see Atul Gawande Big Med)
“Proactive Office Encounter” (POE), ensures consistent evidence-based care at every encounter across the organization. At its core, the POE is an agreement of process and delegation of tasks between physicians and their administrative supports.

Glossary:
Medical assistants (MAs)
Licensed vocational nurses (LVNs)

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CREDIT HBR Case Study on SCPMG Primary Care Best Practice

How One California Medical Group Is Decreasing Physician Burnout
Sophia Arabadjis
Erin E. Sullivan
JUNE 07, 2017

Physician burnout is a growing problem for all health care systems in the United States. Burned-out physicians deliver lower quality care, reduce their hours, or stop practicing, reducing access to care around the country. Primary care physicians are particularly vulnerable: They have some of the highest burnout rates of any medical discipline.

As part of our work researching high-performing primary care systems, we discovered a system-wide approach launched by Southern California Permanente Medical Group (SCPMG) in 2004 that unburdens primary care physicians. We believe the program — Complete Care — may be a viable model for other institutions looking to decrease burnout or increase physician satisfaction. (While burnout can easily be measured, institutions often don’t publicly report their own rates and the associated turnover they experience. Consequently, we used physician satisfaction as a proxy for burnout in our research.)

In most health care systems, primary care physicians are the first stop for patients needing care. As a result, their patients’ needs — and their own tasks — vary immensely. A primary care physician’s work includes vaccinations, screenings, chronic disease prevention and treatment, relationship building, family planning, behavioral health, counseling, and other vital but time-consuming work.

Some studies have examined just how much time a primary care physician needs to do all of these tasks and the results are staggering. To be in full compliance with the U.S. Preventive Services Task Force recommendations, primary care physicians with average-sized patient populations need to dedicate 7.4 hours per day to preventative care alone. Taken in conjunction with the other primary care services, namely acute and chronic care, the estimated total working hours per primary care physician comes to 21.7 hours per day, or 108.5 hours per week. Given such workloads, the high burnout rate is hardly surprising.

While designed with the intent to improve quality of care, SCPMG’s Complete Care program also alleviates some of the identified drivers of physician burnout by following a systematic approach to care delivery. Comprised of 8,500 physicians, SCPMG consistently provides the highest quality care to the region’s 4.4 million plan members. And a recent study of SCPMG physician satisfaction suggests that regardless of discipline, physicians feel high levels of satisfaction in three key areas: their compensation, their perceived ability to deliver high-quality care, and their day-to-day professional lives.

Complete Care has four core elements:

Share Accountability with Specialists
A few years ago, SCPMG’s regional medical director of quality and clinical analysis noticed a plateauing effect in some preventative screenings where screenings rates failed to increase after a certain percentage. He asked his team to analyze how certain patient populations — for example, women in need of a mammogram — accessed the health care system. As approximately one in eight women will develop invasive breast cancer over the course of their lifetimes, a failure to receive the recommended preventative screening could have serious health repercussions.
What the team found was startling: Over the course of a year, nearly two-thirds of women clinically eligible for a mammogram never set foot in their primary care physician’s office. Instead they showed up in specialty care or urgent care.

While this discovery spurred more research into patient access, the outcome remained the same: To achieve better rates of preventative and chronic care compliance, specialists had to be brought into the fold.
SCPMG slowly started to share accountability for preventative and chronic care services (e.g., treating people with hypertension or women in need of a mammogram) with high-volume specialties. In order to bring the specialists on board, SCPMG identified and enlisted physician champions across the medical group to promote the program throughout the region; carefully timed the rollouts of different elements of the program pieces so increased demands wouldn’t overwhelm specialists; and crafted incentive programs whose payout was tied to their performance of preventative and chronic-care activities.

This reallocation of traditional primary care responsibilities has allowed SCPMG to achieve a high level of care integration and challenge traditional notions of roles and systems. Its specialists now have to respond to patients’ needs outside their immediate expertise: For example, a podiatrist will inquire whether a diabetic patient has had his or her regular eye examination, and an emergency room doctor will stitch up a cut and give immunizations in the same visit. And the whole system, not just primary care, is responsible for quality metrics related to prevention and chronic care (e.g., the percentage of eligible patients who received a mammogram).

In addition, SCPMG revamped the way it provided care to match how patients accessed and used their system. For example, it began promoting the idea of the comprehensive visit, where patients could see their primary care provider, get blood drawn, and pick up prescribed medications in the same building.

Ultimately, the burden on primary care physicians started to ease. Even more important, SCPMG estimates that Complete Care has saved over 17,000 lives.

Delegate Responsibility
“Right work, right people,” a guiding principle, helped shape the revamping of the organization’s infrastructure. One fundamental move was to transfer tasks from physicians — not just those in primary care — to non-physicians so physicians could spend their time doing tasks only they could do and everyone was working at the top of his or her license. For example, embedded nurse managers of diabetic patients help coordinate care visits, regularly communicate directly with patients about meeting their health goals (such as weekly calls about lower HbA1c levels), and track metrics on diabetic populations across the entire organization. At the same time, dedicated prescribing nurse practitioners work closely with physicians to monitor medication use, which in the case of blood thinners, is very time intensive and requires careful titration.

Leverage Technology

SCPMG invested in information technologies that allowed patients to schedule visits from mobile apps, access online personalized health care plans (e.g., customized weight-loss calendars and healthy recipes), and manage complex schedules (e.g., the steps prior to a kidney transplant). It also established a small outreach team (about four people) that uses large automated registries of patients to mail seasonal reminders (e.g., “it’s time for your flu vaccine shot”) and alerts about routine checkups (e.g., “you are due for a mammogram”) and handle other duties (e.g., coordinating mail-order, at-home fecal tests for colon cancer). In addition, the outreach team manages automated calls and e-mail reminders for the regions 4.4 million members.

Thanks to this reorganization of responsibilities and use of new technology, traditional primary care tasks such as monitoring blood thinners, managing diabetic care, and tracking patients eligibility for cancer screenings have been transferred to other people and processes within the SCPMG system.

Standardize Care Processes
The final element of Complete Care is the kind of process standardization advocated by Atul Gawande’s in his New Yorker article “Big Med.” Standardizing processes — and in particular, workflows — removes duplicative work, strengthens working relationships, and results in higher-functioning teams, reliable routines and higher-quality outcomes. In primary care, standardized workflows help create consistent communications between providers and staff and providers and patients, which allows physicians to spend more time during visits on patients’ pressing needs.
One such process, the “Proactive Office Encounter” (POE), ensures consistent evidence-based care at every encounter across the organization. At its core, the POE is an agreement of process and delegation of tasks between physicians and their administrative supports. It was originally developed to improve communications between support staff and physicians after SCPMG’s electronic medical record was introduced.
Medical assistants (MAs) and licensed vocational nurses (LVNs) are key players. A series of checklists embedded into the medical record guide their work both before and after the visit. These checklists contain symptoms, actions, and questions that are timely and specific to each patient based on age, disease status, and reason for his or her visit. Prior to the visit, MAs or LVNs contact patients with pre-visit instructions or to schedule necessary lab work. During the visit, they use the same checklists to follow up pre-visit instructions, take vitals, conduct medication reconciliation and prep the patient for the provider.

Pop-ups within the medical record indicate a patient’s eligibility for a new screening or regular test based on new literature, prompting the MAs or LVNs to ask patients for additional information. During the visit, physicians have access to the same checklists and data collected by the MAs or LVNs. This enables them to review the work quickly and efficiently and follow up on any flagged issues. After the visit with the physician, patients see an MA or LVN again and receive a summary of topics discussed with the provider and specific instructions or health education resources.

Contemporary physicians face many challenges: an aging population, rising rates of chronic conditions, workforce shortages, technological uncertainty, changing governmental policies, and greater disparities in health outcomes across populations. All of this, it could be argued, disproportionately affect primary care specialties. These factors promise to increase physician burnout unless something is done by health care organizations to ease their burden. SCPMG’s Complete Care initiative offers a viable blueprint to do just that.

Sophia Arabadjis is a researcher and case writer at the Harvard Medical School Center for Primary Care and a research assistant at the University of Colorado. She has investigated health systems in Europe and the United States.

Erin E. Sullivan is the research director of the Harvard Medical School Center for Primary Care. Her research focuses on high-performing primary care systems.