The Elite 8 – Summertime Edition

elite-eight_waterBernadette Keefe MD

Introduction

In U.S. collegiate sports, “The Elite Eight“, are the final eight teams in the national tournament; two from each region. The outcome of those four games becomes, “The Final Four”. However, for this summer time edition of The Elite Eight, we’re talking about the revered “eight glasses of plain water per day” health dictum.

While optimal hydration is essential for health, and water is considered the “gold standard” of hydration, we do not need 64 ounces of plain water a day. We do, however, need 64 ounces or 1.9 liters of total fluid obtained via drinks and food for optimal functioning and health, especially during the warm weather and exercise.

Furthermore, what makes the eight glasses of water per day advice “elite”/special is that consuming a zero calorie beverage might just be the antidote to the current epidemic of obesity and Type 2 diabetes. Americans typically satisfy their thirst with sugary beverages. Shockingly, these drinks contribute the majority of our daily ingestion of sugar! Continue reading

{Ultra}Processed Food: Too Sexy for Our Own Good?

FrenchFries

Bernadette Keefe MD

“If we are what we do and what we eat, we’re potatoes: couched and fried.” – Ellen Goodman, Wall Street Journal

Introduction

Fast Food has a rich and storied history. In Roman times, through the middle ages, fast food, sold by venders, was a necessity, as many dwellings had no kitchen.

The British “Fish ‘N Chips” was popularized in the mid-1800s by coastal towns that needed to service the large trawling industry. The undisputed King of the Fast Food Industry, however, is the United States. With the introduction of the automobile in the early 1900s, there was ever greater access to fast-cook restaurant fare. America fell in love with “White Castle” hamburgers; the rest is history. America has the largest fast food industry, and, has peppered the world’s landscape with Subway, McDonalds, Kentucky Fried Chicken, Burger King, Starbucks, Dunkin Donuts, Wendy’s among others, whose outlets can be found in over 100 countries.

Due to its worldwide dominance of the Fast Food Industry, U.S. citizens are particularly immersed in the fast food culture, and sadly have “drunk the cool-aid”. While this essay addresses the effects of fast food and other ultra-processed food in America, similar consequences are occurring around the globe.

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Gamification in Healthcare – Let’s Play!

games-geek-dice-nerd-gold-dnd-ancient-dungeons-and-dragons-board-games-games-20-sided-die-HD-Wallpapers

Bernadette Keefe MD

 “Playing a game is the voluntary effort to overcome unnecessary obstacles.” (Bernard Suits)

Introduction

Game-play focuses and controls our attention, taps into our innate strengths, thrills us utterly, and compels us to greater resilience in the attainment of more powerful and effective skills. For these reasons, some believe that game-play is an invaluable tool to employ in tackling the biggest problems in our world today.

The ability of gaming to focus human attention so completely has attracted all those who wish to harness just a piece of that attention for their own ends. Business, education, and healthcare have all used gamification with the hopes of affecting certain desired behaviors. The goals of gamification in healthcare would be no less than to effect personal and societal behavior change, to achieve improved individual health, and the health of populations.

A flurry of aspirational papers and some early results propelled gamification in healthcare to a Gartner’s Hype Cycle * peak ‘hype’ in 2011-2013. Years 2014-2015 found gamification in healthcare in a period of disillusionment. Now the sentiment for gaming seems to be on the upswing, as more attention is being paid to high quality game design and targeted use.

 In this paper, I will give some history and context to game play, video game design, and the gameful mindset to show how gamification in health and healthcare can and does happen successfully when done well. I will also include demonstrative examples and a large number of references for further perusal.

What is A Game

Games are a structured “form of play or sport, especially a competitive one played according to rules and decided by skill, strength, or luck.” –wikipedia

The history of gaming goes back to ancient times and game-play is one of the oldest forms of social interaction. In essence, the games we play are a celebration of our potential, our dreams, and our innermost passions. Game-play is self-revelatory, and, at the same time, takes us ‘out of ourselves’.

The vast variety of game forms, both ancient and modern, speaks to the centrality of games, and game-play in human life. We play games seated, across from each other, standing, poised ‘in combat’ at the 50 yard line in stadiums, and across the world, in online video games. We stand, jump, kick, run for both online and offline physical games. ‘Exergaming’, the combination of video gaming and exercise, has taken individual and group exercise to a new level. The brilliant ancient Chinese game of ‘Go’, a territorial board game of strategy, is played with as much passion today, as it was several centuries ago!

Game-Collage

Collage of Non-Sport Gaming

Continue reading

Boomers, Got Fit (bit)?

Boomers – Got Fit (bit)?

Best-activity-trackers_banner-r1

Bernadette Keefe MD

“You can’t manage what you don’t measure.”                              

 (credited to by not said by W. Edwards Deming)

 Introduction

If you are 50 years of age or older you are a baby boomer, that means by 2030, there will be 77 Million people over the age of 65 in the U.S. alone. The U.S. National Institute of Aging has designated September as a Go-4-Life month: a national exercise and physical activity campaign for people 50+. The goal is to empower older adults to become more physically active. The last week in September marks the beginning of Active Aging Week (September 27 – October 3) for the United States, Canada and Australia. Each day is devoted to a specific healthy life habit: from walking to nutrition to social connection.

The importance of our lifestyle/behaviors, to overall health is now undeniable. It is thought that 70% of chronic disease is caused directly or indirectly by the poor lifestyle choices we make. Now we can seamlessly measure our daily behaviors through fitness trackers. Continue reading

Quadruple Aim: Care of the Physician

Quadruple Aim

By Bernadette Keefe MD and Matthew Katz MD

The classic ‘triple aim’ for healthcare is a framework developed by the Institute for Healthcare Improvement (IHI) that describes an approach to optimizing health system performance. IHI asserts that new designs must be developed to simultaneously pursue three dimensions which we call the ‘Triple Aim’:

  • Improving the patient experience of care (including quality and satisfaction)
  • Improving the health of populations, and
  • Reducing the per capita cost of health care

Numerous publications suggest that the list be expanded to a ‘Quadruple Aim’ to include: Improving the Care of and Experience of The Provider (ie MDs/other HCPs).

Continue reading

The 100 Year Lifespan.

aging-fashion

The quality, not the longevity, of one’s life is what is important.

– Martin Luther King Jr.

100 Year Lifespan: The coming reality

The 100 Year lifespan is coming. As of 2014 there were 72,000 centenarians (U.S.) and projections of as many as 1 million by 2050. In the industrialized world, people over 90 years of age are the fastest growing segment of the population. By the end of this century the average life expectancy is expected to be 100 years. Notably, Japan’s centenarians, who number about 30,000, have quadrupled in the last 10 years.

Now there are 43 Million Americans over age 65 years age. By 2050 that number is expected to rise to 108 million. The number of those over 85 years could increase five-fold by that time.

Continue reading

Uncertainty: Can We Take It? (& Avoid Over-Diagnosis/Over-Treatment)

 

embracing-uncertainty-mindmap

Bernadette Keefe MD

“Man lives in a world of surmise, of mystery, of uncertainties.” – John Dewey

The practice of medicine is both an art and a science, filled with uncertainty. Seemingly overnight, a tremendous amount of uncertainty has entered the healthcare arena, even apart from the financial /insurance, regulation/government and technological/electronic record issues. This uncertainty is starkly apparent at the point of care, when people seek professional advice from physicians. There are three major facets of uncertainty during consultation:

  1. The ongoing changing relationship between patients and physicians
  2. The uncertainty of the information within and significance of medical test results
  3. The uncertainly about the veracity of the vast body of medical research

The Changing Physician/Patient Relationship, and Complications Within It

As physicians we are expected to:

  1. Listen to our patients more attentively;
  2. Provide them with as much data about their disease as possible;
  3. Recommend further reading on their conditions; and
  4. To be much more mindful of the patientʼs goals and to consider the social context when recommending treatments.

As Patients we are expected to:

  1. Be interested and engaged in shared decision making about our course of care and treatments.
  2. Take better care of ourselves, to exercise, eat nutritionally, to get enough sleep, to not smoke, to avoid addictions and to maintain a healthy social life .

Implicit in this is that both physicians and patients would have access to the necessary patient data to enable safe, informed care. Sadly in this era of little to no interoperability, the results of outside testing and consultation are often not available at point of care.

The Quest for Certainty Thru More Testing 

Humans fear uncertainty, tending to do anything to resolve questions and reduce risk. In healthcare that usually means more tests and diagnostic procedures to answer nagging questions. Both physicians and patients fear uncertainty. 

From A Surgeon:

The noted author/surgeon; Atul Gawande MD addressed this subject in his New Yorker article “Overkill”:

“As a doctor, I am far more concerned about doing too little than doing too much. Itʼs the scan, the test, the operation that I should have done that sticks to me – sometimes for years.

Why not take a look and see if anything is abnormal?

And patients often feel the same way. Theyʼre likely to be grateful for the extra test done in the name of “being thorough…”

but

“Resolving the uncertainty of non-normal results can lead to procedures that have costs (and complications) of their own”.

From An Emergency Medicine Physician:

A recent survey of emergency department physicians, focusing on imaging tests, revealed that over 90% of them ordered unnecessary tests out of fear of error, uncertainty, and other non-medical reasons. Hamal Kanzaria M.D the lead author commented about the results:

“Overall I interpret our results (as reflecting on) a cultural response both within and outside medicine to uncertainty and error.

I personally think that to overcome overtesting we need to address our collective intolerance of uncertainty both within medicine and within society at large, as well as the culture of blame that triggers the malpractice system.”

From A Radiologist:

In his piece, “Who is the better radiologist? Hint: itʼs not easy”, Dr Saurabh Jha, a radiologist, asks us to think about the trade offs between certainty and risk, between sensitivity or specificity with respect to interpretation of radiologic studies. Given perfection is unattainable, do we lean towards the underdiagnosis or overdiagnosis spectrum?

As Dr Jha states in his piece (he uses a fictional Dr Jha and Dr Singh for purposes of illustration (please see the article to put this in context) that we vacillate about what kind of radiologist we would want reading our study depending on the known outcome.

“If I had a missed tiny cancer on chest X-Ray, I would have wanted Dr. Jha to have read my study”

(The fictional Dr. Jha over reads, misses nothing but calls every incidental finding, 99% are nothing but many of these evaluated because of his reading: surgery, complications or worse).

but

“If I had no cancer I would have wanted Dr. Singh to have read my Xray.”

(The fictional Dr Singh only calls major findings, not mentioning small findings he interprets to be incidental findings, thus avoiding needless work up, possible complications and waste.)

However, we do not know the outcome of a study ahead of time so each of us, as patients and physicians must decide in each circumstance what level of uncertainty is tolerable for us. Are we going to try to quell every tinge of uncertainty no matter the cost to ourselves (and others)? Or can we tolerate living with some uncertainty, living with those non-normal findings that we do not investigate.

environmental uncertainty

 

 

 

 

 

 

 

 

Uncertainty of Truth of Published Research

With more transparency and unbiased evaluation of the literature, we are learning that there is a tremendous amount of uncertainty about the body of research which had been considered evidence based, but now is often seen to be unreproducible. For instance a treatment course entered into now may be found unhelpful or even dangerous a year or worse – 10 years from now. As George Lundberg MD just wrote in Medscape about the work of John Ioannidis on the inaccuracy of most of the body of medical literature:

“The mathematics, the psychology, and a misunderstanding or deliberate ignoring of the overriding importance of positive predictive values negate the validity of most – and he means most – published research.

John (Ioannidis) argues persuasively that many forms of bias operate in affected domains, fields, cultures, peopleʼs heads, reward systems and ecologic groups.”

In the article, Dr Lundberg lists 12 steps to improve the body of medical research including:

  • adopting a culture of replication
  • more collaboration and transparency
  • better training and standards
  • improvement in peer review
  • improvement in reporting and dissemination of research results
  • I would add to them: open access and patient inclusion in study design.

Below is an excerpt from a blog post by Dr John Mandrola, cardiologist, citing a recent article in the journal Mayo Clinic Proceedings about the dramatic number and subsequent effect of medical reversals. (Medical reversals are advice and treatments, including drugs, procedures, surgery which were formerly recommended, that are now shown to be useless or harmful.)

“The authors emphasize three reasons why medical reversals are so serious. First millions of humans were harmed. The second issue is continuing harm. Some estimates suggest it takes ten years – on average – to change entrenched medical practice…Third, medical reversals cause harm because they erode trust in the patient – doctor relationship. Patients expect doctors to be either correct, or transparent about uncertainty.”

and

“This is not just important information for doctors. Patients seeking medical treatment should not assume a prescribed therapy is beneficial just because a doctor says it is. The era of paternalism in Medicine is over. Patients should be able to ask their doctor whether the evidence supports the intervention. Itʼs okay if the doctor is uncertain. In fact, doctors who are too sure of things worry me.”

Conclusion

So now what?

Just at a time when patients are becoming empowered, shared decision making has becoming a reality, and physicians are listening more, we realize that much of the literature (ever increasing and replete with reversals) is partially or almost completely in error. Just at the time we need, more than ever, real time access to patient data, we have instead, widespread lack of interoperability.

The confluence of scared but empowered patients, a flawed body of medical literature , a new paradigm of shared decision making, unworkable information technology, an endless supply of “sexy” new technologies, a hangover from a culture of medical paternalism and overwhelmed physicians necessitates an urgent need for a “time out”.

A time out invites both physicians and patients, to reflect on the centrality of uncertainty in life, to resurrect compassion for and listen more attentively to one another, and, to embrace humility regarding the human condition.

 

uncertainty qote

BK

Addendum: I am currently Storifying the 2016 #EvidenceLive conference, from June 21-24, Oxford, England. This important conference is relevant to this post.

My #EvidenceLive Storifys thus far:

June 21: Pre-conference workshops

https://storify.com/nxtstop1/the-evidencelive-conf-via-evidencelive-oxford-eng-

June 22 Day 1 Part 1

https://storify.com/nxtstop1/the-evidencelive-conf-via-evidencelive-oxford-eng–576a49d3496bcc774b68e3da

June 22 Day 1 Part 2

https://storify.com/nxtstop1/the-evidencelive-conf-oxford-june-22-24-2016-curat

 

With thanks:

Header Image Credit: Adam Sicinski

http://www.mindmapart.com/embracing-uncertainty/

References

“Risks, Benefits and Uncertainty in Health Care”, Health Affairs, May/June 2007, http://content.healthaffairs.org/content/26/3/624.full.pdf+html, accessed May 16 2015

“Coping with Uncertainty in Primary Care”, Dr Richard Draper, PatientPlus, April 2010,http://www.patient.co.uk/print/1541, accessed May 16 2015

“Varieties of Uncertainty in Healthcare: a conceptual taxonomy”, Paul K J Han, William M P Klein, Neeraj K Arora, Medical Decision Making, December 2011,http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146626/, accessed May 16 2015

“Overkill”, Atul Gawande, New Yorker, May 11 2015,http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande, accessed May 16 2015

“Changing the culture of American Medicine – Start by removing hubris”, Dr John Mandrola, Dr. John M Blog, July 8 2013, http://www.drjohnm.org/2013/07/changing-the-culture-of-american-medicine-start-by-removing-hubris/, accessed May 16 2015

“Who Is The Better Radiologist: Hint, it’s Not That Easy”, Saurabh Jha, Kevinmd.com, August 9 2014,http://www.kevinmd.com/blog/2014/08/better-radiologist-hint-easy.html, accessed May 16 2015

“97% of ED Physicians Order Unnecessary Tests”, John Commins, HealthLeaders Media, March 30 2015, http://www.healthleadersmedia.com/content/PHY-314799/97-of-ED-Physicians-Order-Unnecessary-Imaging-Tests, accessed May 16 2015

“Clinical Decision Support: The elixir of Healthcare?”, Nathan Buzza, LinkedIn Pulse, March 8 2015,https://www.linkedin.com/pulse/clinical-decision-support-elixir-healthcare-nathan-buzza, accessed May 16 2015

“The Certainty of Uncertainty in Medicine”, Dr Lundberg, Medscape, May 2015,http://www.medscape.com/viewarticle/844488, accessed May 16 2015 (subscription requied)

“Why Most Published Research Findings Are False”, John P A Ioannidis, August 2005,http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182327/, accessed May 16 2015

The Case For Teaching Ignorance http://www.nytimes.com/2015/08/24/opinion/the-case-for-teaching-ignorance.html

Image Credit: Dr. Seuss sign made by eureka

FYI Topics for the #hcldr tweet chat on Tuesday May 19, 2015 were:

  • T1 Ask your physician to investigate everything or live with non-normal findings that are most likely benign: Where do you fall on the continuum?
  • T2 Which radiologist would you prefer: attention to every little finding/order every test OR just big stuff/order a few tests maybe miss small things?
  • T3 When there is uncertainty about best course of treatment or diagnostic testing, are you more or less apt to just let “doc decide”?
  • T4 What are the best solutions to all this uncertainty? Interoperability? Better research? Less litigation? Less blame? Accountability? Facing the reality of the human condition? More humility for all?