My 12 Favorite Books I Read in 2010

In no particular order:

1. Nassim Nicholas Taleb: The Bed of Procrustes (Aphorisms that make me think)

2. Tom Chatfield: Fun Inc: Why gaming will dominate the twenty-first century (the theory behind why video games are so popular and why they just might transform health care and education)

3. Siddhartha Mukherjee: The Emperor of All Maladies: A Biography of Cancer (As a pathologist, I am fascinated by the journey of a young medical oncologist and the history and biography of cancer)

4. Vinnie Mirchandani: The New Polymath (There is a lot here to make me think about the future of health care)

5. Lionel Shriver: So Much for That (a novel that captures the misery of the status quo of health care in the USA)

6. Gary Shteyngast: Super Sad True Love Story ( I love this novelist)

7. Yunte Huang: Charlie Chan (I watched the movies as a kid on channel five in LA)

8. Rebecca Skloot: The Immortal Life of Henrietta Lacks (A book where the author becomes part of the story, but the tragedy is how the gap between the medical profession and the family is so vast)

9. Sam Lipsyte: The Ask

10. Oren Harman: The Price of Altruism (Why do we do nice things for others)

11. Melvin Rogers: The Undiscovered Dewey (This book made me rethink my whole understanding of Dewey)

12. Justin Spring: Secret Historian: The Life and Times of Samuel Steward, Professor, Tattoo Artist and Sexual Renegade (Truth is definitely stranger than fiction in this case. You just cannot make this stuff up)

Will the BCS Computer Let Kendal-at-Hanover Play UCLA in a Bowl Game?

I have been thinking about the difference between slow medicine and UCLA medicine. It has made me realize how complex and difficult it is to transform American health care so that we lower per-capita cost and increase the quality of our lives. And yet we must achieve these two goals.

Slow medicine is practiced by a small, but growing subculture whose pioneer and spokesperson is Dr. Dennis McCullough, author of the book My Mother, Your Mother: Embracing “Slow Medicine,” The Compassionate Approach to Caring for Your Aging Loved Ones. Slow medicine is a philosophy and set of practices that believes in a conservative medical approach to both acute and chronic care. (http://ow.ly/3jnBU)

McCullough describes slow medicine as “care that is more measured and reflective, and that actually stands back from rushed, in-hospital interventions and slows down to balance thoughtfully the separate, multiple and complex issues of late life.” Shared decision-making, community and family involvement, and sophisticated knowledge of the American health care system are some of the slow medicine practices that sharply contrast with UCLA medicine. (http://ow.ly/3jnBU)

UCLA medicine is the status quo where the hospital is the center of the medical universe; where care is often uncoordinated and hurried, and where cure is the only acceptable outcome for both patient and physician. I call it UCLA medicine because the CEO of that well-regarded medical center was quoted in a New York Times Sunday Magazine article as saying, “If you come into this hospital, we’re not going to let you die.” (http://ow.ly/2Ys4n) This is a statement that puzzles me as an old time anatomic pathologist.

Slow medicine vs. UCLA on Sunday night football. Sports metaphors do not capture the complexity of modern American health care. Let me hasten to say at the start that there are times (serious acute illness correctly diagnosed where there is an evidence-based treatment that has a good chance of success) when I hope I am treated in UCLA’s ICU or operating room by UCLA specialists. However, there are also times as I get older that I hope I end up living in the Kendal-at-Hanover retirement community cared for by a wise and experienced geriatrician like Dennis McCullough and the community’s nurse practitioner; I want my providers to take things slowly and listen to what I want out of life.

This tension between slow and fast is not new, and it is not limited to American health care. The monastic culture of the Latin West in the fifth century was epitomized by the Benedictine monasteries which had “a distinctive approach to texts, one that might be called ‘slow writing and reading’ – and that contrasts as sharply with contemporary practices in reading and writing as Slow Food does with McDonald’s.” Benedictine monks by rule were allowed to read only one book a year; the idea was they should slowly and carefully understand and reflect on what they read. (http://ow.ly/3j9W2) As a modestly reflective physician who is on twitter every day, I think I am more comfortable with someplace in the middle of the monastery/twitter continuum of speed of thought and reflection.

I also think it is a mistake to place technology squarely on the UCLA medical team. I myself have sometimes fallen into this trap, but again I think it is complicated. In talking about pelvic prolapse with an experienced clinical professor of OB/GYN at a major Eastern academic medical center, I at first tried to contrast the low-tech pessary solution with the high-tech surgical solutions. My clinician colleague who prides herself on shared decision-making and her vast knowledge of different types of pessaries and different kinds of patients in her busy practice refused to be pigeonholed as either a slow or fast gynecologist. Some patients need and want pessaries; other patients need and want surgery.

I am also slowly starting to realize that high tech solutions can and will be part of the slow medicine tool kit. Dr. Joseph C. Kvedar’s concept of Emotional Automation involves humans easily developing trusting relationships with technology. It is hard to argue with Karen the virtual wellness coach/avatar who gets her human walkers to exercise more or the Boston hospital patients who prefer a robot discharge planner to a human one. I am still stunned that patients would rather talk to a robot than a human being, but their reasons make sense. The robot is not in a hurry; it does not talk down to the patient, and the patient can ask the robot the same question over and over again. The busy human discharge planner not so much. (http://e-patients.net/index.php?s=fox)

At first I did not believe that teens with chronic illness would allow Stanford researchers to track their moods by monitoring the songs on their iPods and the words in their text messages. By providing feedback on what saddens the teens, they were able to improve adherence to medications. Sussanah Fox taught me that the teens trust technology that is portable, and it is certainly better than being nagged by their mothers to take their pills. (http://e-patients.net/index.php?s=fox) In a USC study, people with social anxiety confessed more of their personal flaws, fears and fantasies to virtual figures programmed to be socially sensitive than to live therapists conducting video interviews. (http://www.nytimes.com/2010/11/23/science/23avatar.html)

I am now convinced that humans will increasingly embrace and trust technology to support slow medicine. People love and trust their iPhones. Smartphones and tablet computers have become personal and an extension of ourselves. “It is different now that we carry our second self with us. We think with the objects we love and we love the objects we think with.” So says MIT’s Sherry Turkle, the pioneering student of evocative subjects. (http://ow.ly/3jjCG) Mark Rolston, chief creative officer of Frog Design, observes that people grieve when they lose a personal electronic device. “You are leaving your brain behind,” he says. (http://ow.ly/3jjCG) So how many of you sleep with your cell phones or participate in online flame wars about iPhone vs. Android? How many of you love your iPod?

Fast UCLA medicine is the status quo, but slow medicine with its shared decision-making, community involvement, and new technologies is slowly gaining ground. We have to embrace slow medicine, when appropriate, because it is the only way we can decrease per-capita cost and increase quality. I agree with Orszag and Obama that we have to teach the patients and doctors in Newark, New Jersey how to practice Portland, Oregon and Salt Lake City medicine in the last two years of life. According to Jack Wennberg’s book Tracking Medicine, patients in Newark spend 35 days in the hospital during their last two years, and people in Portland and Salt Lake City spend 12 days. (http://ow.ly/3jnGq) I would like UCLA to emulate Mayo Clinic in their end of life care so that we can save $700 billion a year and improve the American economy for us all. (http://ow.ly/2YrRu)

I first started thinking about this stuff in a June 21, 2010 blog post about whether the internet is good or bad for us (http://ow.ly/3jme5). I can still remember the ambivalent feelings I had then about paro, but I ended that blog with the following:

“So where does that leave me with Paro, the cute little seal robot that seems to comfort some old people in nursing homes with dementia? I don’t like Paro because it is not alive and is not a genuine harp seal puppy. I would prefer that all old people with dementia have a caring human being to be there for them. If a human is not available for whatever reason, I would prefer that a live puppy be there to cuddle. (Full disclosure, I love bichons, two in particular). If people and puppies are not available, I see no reason not to use Paro.

Holding her seal robot, Lois Simmeth, 73, who lives in a Pittsburgh nursing home says, ‘I love animals. I know you’re not real but somehow, I don’t know, I love you.’ (http://ow.ly/21cj7) Love is good, plain and simple.”

Gratitude and Health, Happiness, and Well Being

Although Cicero identified gratitude as the chief virtue and religious traditions have long used specific prayers to nurture this practice, social science has only recently studied the effect of gratitude on wellness. “Scientists are latecomers to the concept of gratitude. Religions and philosophies have long embraced gratitude as an indispensable manifestation of virtue, and an integral component of health, wholeness, and well-being,” writes UC Davis’ Robert Emmons. (http://ow.ly/1aa4CC)

Emmons defines gratitude as “a felt sense of wonder, thankfulness, and appreciation for life.” Cultivating gratitude involves concentrating on the present moment and recognizing others who have contributed to where you are today. (http://ow.ly/3ghZZ)

Inspired by the Positive Psychology Movement which concentrates on developing human strengths rather than treating mental illness, Emmons and his colleague Michael McCullough at the University of Miami pioneered rigorous study of how gratitude can effect human health. Their landmark studies involved contrasting the psychological, physical, and social well being of subjects who wrote down five things that they were grateful for with subjects who kept track of five complaints about their lives. (http://ow.ly/1aa4CC)

Adults who cultivate gratitude have more energy, more optimism, higher earnings, more social connections, more happiness, more sleep, more exercise, and more resistance to viral infections than those who do not. They are also less likely to be depressed, envious, greedy, or alcoholics. (http://ow.ly/3gi1L) Although the first research subjects were university students, Emmons has now repeated similar experiments with several others including organ transplant recipients, adults with chronic neuromuscular disease, and healthy fifth-graders. (http://ow.ly/1aa4CC)

Jeffrey J. Froh at Hofstra has extended this line of research by studying children. Grateful children are less materialistic, get better grades, set higher goals, complain of fewer headaches and stomach aches, and feel more satisfied with their friends, families, and schools than children who do not practice gratitude. (http://ow.ly/3gi1L)

Sonja Lyubomirsky of UC Riverside describes eight ways that gratitude can boost happiness. Grateful thinking promotes the savoring of positive life experiences; savoring is defined as behaviors capable of “generating, intensifying, and prolonging enjoyment.” Cultivating gratitude bolsters self-worth and self- esteem. People who are grateful cope better with stress and trauma. Expressing gratitude encourages moral behavior. Grateful thinking encourages and strengthens relationships with others. People who express thanks are less likely to make invidious comparisons with others. Expressing gratitude deters anger, bitterness, and greed. Gratitude counteracts hedonic adaptation, which explains why the happiness we experience after a positive event is so short-lived. (http://ow.ly/3ghZZ)

Several leaders of the Positive Psychology Movement have developed scientifically based exercises to help us cultivate gratitude. Martin Seligman suggests writing a one-page testimonial to someone from your past who has made a major positive difference in your life. Meet with them in person to read out loud your essay and then reminisce together about your past history together. (http://ow.ly/3gi34) Lyubomirsky recommends keeping a gratitude journal where you regularly record your blessings. (http://ow.ly/3ghZZ) Emmons writes about watching your language because disparaging words reinforces negativity, and he also suggests learning prayers of gratitude if you are religious. (http://ow.ly/1aa4CC) A Buddhist exercise instructs people to ask themselves the following questions daily: “What have I received from…? What have I given to…? and What trouble have I caused…?” (http://ow.ly/3gi1L)

Emmons believes all can have a more grateful approach to life, but it requires hard work. One who practices gratitude cannot be a victim or entitled. In order to cultivate this practice one must be able to recognize one’s shortcomings and dependence on others. “Far from being a warm, fuzzy sentiment, gratitude is morally and intellectually demanding. It requires contemplation, reflection, and discipline. It can be hard and painful work,” writes Emmons. (http://ow.ly/1aa4CC)

Anyone who knows me or has worked with me knows that my nature can be sarcastic and cynical. I have a lot of work to do in this area, but I am trying it out; it works. I am especially working on a better sieve mechanism to prevent the almost spontaneous generation of disparaging and sometimes accurate words to describe my world and fellow human beings.

Hospitals Need To Focus On Culture In Order to Be Able to Survive in an Era of Accountable Care Organizations and Medicaid Reimbursement Rates

When a health system asked me to facilitate a Board discussion on physician alignment and integration on November 12, 2010, I was already committed to giving a keynote on the future of health care for the American Institute of CPAs in Las Vegas on November 11. Although I usually fly Delta or USAir where I have priority frequent flyer status, the only way I could get to the Board meeting was by flying from Las Vegas on Southwest Airlines.

My experience on Southwest reminded me of the importance of culture in navigating change in a rapidly evolving environment like we have in health care in the United States today. It is all too easy to focus on all the technical issues hospitals face in setting up Accountable Care Organizations to handle the inevitable global payments that will replace the current fee for service system. This blog is a plea for hospitals and doctors and consultants to pay attention to both the technical and the cultural or adaptive challenges we face in transforming a $2.5 trillion American industry.

Recent articles on companies outside of health care have highlighted how important culture has been to the success or failure of Southwest Airlines (http://ow.ly/3dbZ9), QVC (http://ow.ly/3dc16), and Zagat (http://ow.ly/3degJ) to respond to changing business conditions. Southwest’s COO states “our culture is our biggest competitive strength,” and the flight attendant and pilots’ union worry about how the recent purchase of AirTran will affect their unique culture. I have seen Southwest pilots help clean up the cabin, and the flight attendant on my recent trip told me she was giving up her day off because the company needed her help. QVC is trying to use the same methods and culture that made selling on TV popular with Internet customers. And Zagat, which had cultural troubles moving from book format to online, is now hoping that smart phone applications will reinvigorate their business model.

Harvard’s Ron Heifetz differentiates between technical and adaptive work (http://ow.ly/3dep5), and I have found this concept useful in working with health systems responding to payment reform. Everyone involved in hospital physician integration efforts will need to undergo a cultural (adaptive) shift because the healthcare reform law and the transition from fee for service to global payments mean the old ways of doing things are not sustainable. Even if all the technical tasks are superbly done, difficulties will arise if the leadership, management, care teams, and physicians still have the old mindset and culture.

In attending conferences and working with hospital CEOs, I have found that there is more emphasis on the technical tasks that need to be accomplished in order to form an Accountable Care Organization than on the culture such a change will require. I have heard a lot of keynotes filled with power point slides on defining the role and reporting structures for newly formed physician leadership teams; creating system-wide operational councils; and specific legal structures of ACOs so they can accept and distribute global payments. These are all important technical tasks, but they will fail if the culture does not change too.

Two concrete example may help make this point. Sony engineers came up with the equivalent of the iPod long before Apple. However, Sony ran into internal obstacles because of its culture. Sony’s leadership and organization was designed to come up with improvements to the next generation of CD players, but the new iPod technology threatened how Sony’s leaders and engineers thought about their product line. They could not overcome the cultural barriers to marketing such a revolutionary product. Sony’s failure was not one of technical expertise; it was and adaptive failure of cultural mindset.

My travels found me in Savannah, Georgia recently having lunch with Joe Scodari who sits on three Boards of Directors in the health care space. Scodari related a similar story of cultural failure to adapt when Kodak engineers invented the digital camera; the film culture at Kodak did not approve marketing such a transformational product that would cut into Kodachrome film sales. Kodak missed out on digital cameras, and film sales plummeted anyway.

So how do hospital system CEOs avoid the fate of Sony and Kodak as they respond to the sweeping changes in the new federal health care reform law? They must focus on both technical and cultural issues. Jane Kornacki and Jack Silversin (http://ow.ly/3det9) who pioneered the physician/hospital compact model and Bob Kegan and Lisa Laskow Lahey (http://ow.ly/3deuN) who developed the immunity to change model for transformation have much to teach all of us. Physician leadership academies are another essential ingredient in transforming culture among newly employed physicians who are not used to being employees.

Southwest Airlines made money when other airlines floundered; they attribute this success to culture. Hospitals that focus on culture and technical tasks will have a better chance of survival in an environment that is increasingly saying you better get ready to survive on Medicaid rates, not private insurance rates.

Top 10 Things I Appreciate After Crazy Week Spent in 5 Different Cities

1. I really like reading by the roaring fire in the fireplace.

2. Walking on a Fall Day by the Wissahickon with leaves coming down.

3. Brut champagne.

4. Talking to my daughter Reva who is visiting from NYC.

5. Catching up on twitter because I was too busy traveling last week.

6. Eating a great lunch at home and not in a restaurant.

7. Not answering the telephone at all.

8. Going out to dinner tonight with friends.

9. My good health.

10. How lucky I have been in my life to have the family, the friends, the jobs I have had.

Top 10 Developments That Give Me Hope About Future of Health Care

Tomorrow I will be giving a keynote address for the American Institute of CPAs conference in Las Vegas (http://ow.ly/37mD9). At first they wanted an overview of federal health care reform and what the future holds for US hospitals and doctors. Latter, they called back and said we want a more hopeful message about the future of American medicine and health care. Do you have any hope?

So I got to thinking about what makes me hopeful about our industry's future? I came up with 10 developments I am very excited about.

1. Shared Decision Making and Slow Medicine

2. Computer Simulation (Think David Eddy's Archimedes)

3. Video games for professional instruction, lifestyle changes, drug adherence

4. Patient social networking sites (Think PatientsLikeMe and DiabetesMine)

5. Smart phones and health care apps including EMRs

6. Patient generated research (Think CureTogether)

7. Reverse innovation (Think GE)

8. PHRs

9. Doctors being replaced by online information from a patient like me for health information

10. Twitter and Facebook.

The AICPA folks would only give me an hour for the keynote so I am going to talk mostly about numbers 1 and 2, but all of these developments give me hope for the future.

How Come Comparative Effectiveness Research Is All the Rage?

Comparative Effectiveness Research (CER) is suddenly a hot topic at all the health care conferences. How come? Everybody agrees that we have to decrease per-capita cost and increase quality. Why? Government programs like Medicare and Medicaid foot more than 50% of our nation’s health bill, and if everything stays the same these programs will go belly up (bankrupt) in 8 years. Big problem.

Health and Human Services (HHS) has defined comparative effectiveness research as conducting and synthesizing research comparing the benefits and harms of different interventions and strategies to prevent, diagnose, treat, and monitor health conditions in “real world” settings. In other words, CER is figuring out what treatments, tests, and drugs work and which ones don’t work.

John E. Wennberg spent a whole career at Dartmouth studying American medicine, and he comes to the startling conclusion that 60% of Medicare is spent on supply sensitive care (physician visits, consultations, imaging exams, and hospital and ICU admissions) and 25% on preference sensitive care (PSA tests, mammography, and elective surgery). Although we assume that this care is based on solid scientific evidence, Wennberg states that “medical science is virtually silent on such matters” as how often to see a patient, what test to order, and whether to admit a patient to the hospital or ICU. Some evidence based medicine experts state that only about 20% of what physicians do is based on sound science.

The American Recovery and Reinvestment Act of 2009 contained $1.1 billion for CER, and the Patient Protection and Affordable Care Act of 2010 put in place a structure including a Patient-Centered Outcomes Research Institute to provide a continuous stream of funding and oversight to CER.

So we just need to do the research, figure out what works, and then have Medicare only pay for treatments and tests that work. That approach will solve the health care budget crisis and pay for care that is evidence-based. Right? Wrong. In the current legislation is language that states that CER findings may not be “construed” as mandates regarding payment or treatment or to deny or ration care.

A quick history of CER in the United States reveals how intense the politics around health care can become. Senator David Durenberger of Minnesota in the 1990s encouraged the government to fund Patient Outcomes Research Teams (PORT) to study the best ways to treat angina, low back pain, cataracts, and benign prostatic hypertrophy. When the 23 member expert PORT panel found little science to support surgery as a first line treatment for low back pain, the back surgeons lobbied Congress. The result was Congress cut CER funding for the PORT; one man’s waste is another man’s revenue.

One way to analyze the intensity of health care in the United States is to take a look at Medicare data for the last two years of life. The Dartmouth Atlas project that Wennberg founded had done just that. In the last two years of life, per-capita Medicare spending at UCLA is $93,842 per patient and $53,432 per patient at the Mayo Clinic. Many have suggested if we could get the entire country to treat such patients like the Mayo Clinic we could save $700 billion a year. Another study looking at the last two years of life found that patients in Newark, New Jersey spend about 35 days in the hospital; patients in Cleveland and San Francisco spend about 20 days in the hospital; and patients in Portland, Oregon, and Salt Lake City, Utah spend only 12 days in the hospital. If the doctors in Portland and Salt Lake City could teach the rest of us how they do it, much of our budget problems would be gone.

If CER is just trying to figure out what is scientifically the best way to diagnose and treat human disease how can anyone be against it?

Princeton health care economist Uwe Reinhardt writing in the New York Times economics blog identifies two groups opposing CER.

“The first group includes individuals or enterprises that book other people’s health care spending as their own health care income.”

“The second group…includes individuals who sincerely believe that health and life are ‘priceless’ – for them cost should never be allowed to enter clinical decisions.”

What seems clear is that American society needs to have a frank and honest discussion about CER, waste, and the American budget deficits. CER itself is not controversial. It is what you do with the results that create political tension and heat. The Kaiser Family Foundation stated the obvious when they wrote recently: “Ultimately, however, conducting research and gaining knowledge about what is clinically effective is only valuable if the findings are used by the health care system.”