Archelle On Health

Rebuttal to Last Week's Blog, Death of Disease Management (Finally)

2012-01-17T09:15:00.000-06:00

Last week's blog, The Death of Disease Management, was well....provocative. It received unexpected broad readership and was reposted on Managed Care Magazine Online.

Here is a fantastic "rebuttal" to my blog by Al Lewis, Executive Director of the Disease Management Purchasing Consortium and someone I consider the "father" of disease management.

In the spirit of collaboration, I am re-posting Al's blog and encourage you to read it. It's this type of constructive dialogue (and banter...which Al is always good for!) that will help identify the opportunities for change that we need to advance health.

Reports of the Death of Disease Management Are Greatly Exaggerated

Submitted by Al Lewis on Sat, 2012-01-14 10:28

There have been unsavory rumors flying around the internet that disease management as practiced today may not be all that effective. I’m not going to reveal who started these rumors but her name rhymes with Archelle Georgiou. This person says disease management is “dead.” Since there are still many disease management departments operating around the country apparently oblivious to their demise (and disease management departments are people too, you know), I suspect this commentator was using the word "dead" figuratively, as in: “The second he forgot the third cabinet department, Rick Perry was dead." (Another example of presumably figurative speech in the death category would be: "After he denounced gays while wearing the Brokeback Mountain jacket, you could stick a fork in him.")

And if the rhymes-with-Archelle commentator intends “dead” as a synonym for “not in very good shape,” she certainly has a point. Not only does she have a point, but I would add more items to her list of reasons for the field's current troubles:
(1) The interval between diagnosis (the point where readiness to change is usually greatest) and successful patient contact can exceed three months;
(2) Predictive modeling “risk scores” that tell you only how sick someone was, dressed up as a “risk score,” not how sick they will be, even though they aren’t already high utilizers;
(3) Some interventions are so expensive that they exceed the cost of the disease;
(4) The physicians are still not involved;
(5) Rather than using actual mathematically sound methodologies to calculate results, many vendors and consultants damage the credibility of the entire endeavor by believing in the Outcomes Fairy.

Fortunately, there are improvements afoot to address all of these issues:
(1) Electronic medical records presage faster claims adjudication, and ICD-10s will mean much more detailed patient information than is possible today. And disease management departments are already coordinating with UM/precertification/discharge planning better than even two years ago. Together, these innovations will match people with programs much faster;
(2) Predictive modeling is increasingly including the lab scores. “Increasingly” meaning that instead of 1% of models having lab data, maybe 3% do. Still, it’s a start. Lab values allow actual prediction, instead of simply drawing a line connecting last year’s high claims to this year’s high risk scores;
(3) The cost of interventions is declining quite rapidly, largely with the advent of mHealth (use of mobile communications devices in health care), which is hugely overrated by venture capitalists as a vehicle for getting rich from, but quite appropriately rated as a way to facilitate contact with members if indeed privacy regulations get rewritten to assume that the only person who answers a cellphone is the owner of that phone, and hence no “opt-in” app is needed;
(4) Some physicians are getting involved because their contractual arrangements and accreditation, such as patient-centered medical homes, are requiring it;
(5) And finally, my own forthcoming book, Why Nobody Believes the Numbers: Separating Fact from Fiction in Population Health Management, will take care of the last item. Imagine the Outcomes Fairy-meets-The Hurt Locker. Credibility will be restored for those vendors whose outcomes are modest but valid. The introduction may be downloaded gratis from www.dismgmt.com .

Is disease management dead? No. It is going through a transition period in which older models are being replaced via “creative destruction” and plain old innovation with newer models. This isn’t too much fun now but ultimately this trial-and-error process should create health-improving interventions that are truly effective in preventing, forestalling and addressing some small but significant portion of the 75% of cost attributable to people with chronic disease.
So I think perhaps these two seemingly conflicting posts are in broad agreement, the only difference being that what I believe is well-founded, evidence-based optimism that the industry can innovate its way out of the current stagnation. On this point, only time will tell. In a few years we should know, to quote the immortal words of that aforementioned great philosopher Rick Perry, whether or not who is right.

Al Lewis is Executive Director of the Disease Management Purchasing Consortium

Originally posted online by Managed Care Magazine

The Death Of Disease Management (Finally)

2012-01-12T12:13:00.005-06:00

In 1995, Dr. Steven Rosenberg published an article in the New England Journal of Medicine (NEJM) that fueled the start of an industry. In a randomized, controlled trial, he showed that an investing in proactive disease management (DM) activities could decrease the cost and improve the quality of life for patients with congestive heart failure.

The premise of disease management seemed intuitive:

· Systematically assure that evidence-based medicine is applied.

· Educate and empower patients to practice self-care.

· Intensely manage the sickest 5-10% of the patients driving 80% of the costs.

Healthplans, employers and other payers (and I) jumped on the bandwagon hoping that these programs would be a consumer-friendly silver bullet to escalating health care costs.

Cardiac Solutions, Matria, LifeMasters and American Healthways, among others, became household names. In addition, business opportunities abounded:

· Disease Management Association of America was founded in 1999.

· NCQA developed an DM accreditation program in 2002.

· Data analytics companies developed predictive modeling tools to better identify the highest risk patients.

· Employee benefits consultants promoted the “new new thing” for cost control.

But, behind the scenes, there was a lot of hand-wringing. On the eve of a major Disease Management conference, circa 2004, I remember sitting in the bar of an Orlando hotel having cocktails with DM gurus who who’d nabbed the coveted keynote speaker spots at this major forum. The Medicare Modernization Act of 2003 had just passed, and CMS had a mandate to test the disease management model in Medicare fee-for-service beneficiaries. I was shocked when my industry colleagues admitted that this $20 billion industry would only last as long as it would take for the pilots programs to be completed and CMS to analyze the results.

In the mean time…double-digit healthcare cost inflation fueled employers demand for a wide array of condition-specific programs as a cost reduction strategy. According to Mercer Consulting, in 2010, 73% of employers offered disease management programs even though consistent, reproducible evidence of a positive ROI is still lacking.

It’s been seven long years since that Orlando meeting…and the time has come when will disease management may finally…finally…. fizzle and die.

The CMS demonstration programs started between August 2005 and January 2006 and preliminary results reported in 2008 concluded that "Results to date indicate limited success in achieving Medicare cost savings or reducing acute care utilization."The individual programs, all using nurse-based call centers, ended between December 2006 and August 2008, and the definitive results were published in NEJM in November 2011. In summary:

Only 2 of 15 programs resulted in reduced hospital admissions. None generated net savings.

There were only 14 significant improvements in process-of-care measures out of 40 comparisons.

These modest improvements came at substantial cost to the Medicare program in fees paid to the disease management companies ($400 million), with “no demonstrable savings in Medicare expenditures.”

So, why did this intuitive approach to managing disease fail?

In my opinion, there have been 3 critical missteps in the evolution of this industry:

1) NCQA Accreditation Standards: NCQA’s health plan accreditation standards require that DM programs be population-based—in other words, that ALL individuals with a condition be eligible for participation--not just those at highest risk who are most likely to benefit clinically and financially. Healthplans and vendors complied to achieve the marketing value of the NCQA gold seal of approval. Employers bought into this approach in the spirit of “prevention.” However, this peanut butter approach allocates time and money to individuals who are so low risk that there is little opportunity for clinically meaningful improvement that translates into financial savings.

2) Toys and Trinkets: From glossy brochures to felt puppets to refrigerator magnets, DM companies have differentiated themselves with collateral materials that have sales appeal but have little impact on improving care or decreasing utilization. At the same time, all these all of these items inflate program costs and erode ROI. At the end of the day, DM that does not achieve a net savings is not successful.

3) Over-reliance on Evidence-Based Medicine: Yes, EBM is the holy grail. However, the sole reliance on these standards in disease management interventions does not actually "manage disease” since avoidable costs are frequently due to subtle opportunities and gaps in care that exist as a result of multiple co-morbidities. For example: A patient in a diabetes DM program may also have rheumatoid arthritis. If the patient’s hand/joint pain is not well managed, it is unlikely that she will be able to comply with manually operating a glucometer to check her blood sugars. Unfortunately, the critical thinking required to truly coordinate care is difficult to systematically build into program design....therefore, too often, its absent.

So, if disease management doesn’t work, what does?

This month, hundreds of health care entities will be submitting proposals to CMS to get a piece of the $1 billion funding available through the Health Care Innovation Challenge. As CMS grants between $1 M and $30 M to various projects, let’s hope that they fund initiatives that reflect fresh, not "same old, same old" thinking for improving health and decreasing cost.

Technologies and platforms that are relatively low cost, scalable and seem the most promising are those that leverage:

1) Social networking—Condition-specific communities of patients continue to proliferate and the user-generated content from “people just like me” is having a positive impact on compliance, self-care, and quality of life.

2) Gaming: Health gaming is extending far beyond Wii Fit. Game developers are designing increasing numbers of consumer-oriented applications that address prevention, healthy lifestyles and disease self-management.

3) Remote monitoring: Biometric and ambient activity sensors offer clinicians and caregivers 24/7 insight to a person’s clinical status so that care can be delivered when it’s needed rather than when it’s scheduled.

4) Mobile/wireless health management applications: In addition to consumer focused health management apps, mobile and wireless access to patient medical information accelerates how physicians make critical diagnostic decisions and can prevent delays in care.

5) Environmental solutions: Innovative companies are poised to transform health care with disruptive products and systems that rely on design thinking--solutions that make it easy to be healthy, passively and continuously support better health, and don't rely on individual behavior change.

Proposals are due January 27, 2012. Awards will be announced in March. Results won’t be in for 3 years.

In the mean time, employers looking for immediate health care cost savings can save $2-5 per member per month in fees by terminating their disease management programs.

Disease Management: RIP

Sweat The Small Stuff

2011-10-25T17:47:00.002-05:00

For the last 2 months, I've exited the blogosphere....and plunged into the dance studio.

As mentioned in my last post, I am a "celebrity" dancer for the Annual CornerHouse Let's Dance event scheduled for November 12. While the evening of the gala will be an exciting finale to four months of preparation, it's really been the process of getting ready that has been extraordinary. Take a look at this 1-1/2 minute video for a 'behind the scenes' glimpse:


Link: Dancing with Bruce, the planet's most patient dance instructor

The video is a humorous promo for the event. The more important transformation transcends the dancing and comes from "the small stuff" --- brief but important moments that made me pause and translated into meaningful insights:

On technology: We selected a song that was 34 seconds too long. At 9:15 am one morning, while driving to work, I used my cell phone to call a professional production company. By 9:25, David (of David & David Productions) had downloaded the song from iTunes and we were discussing the areas to splice. At 9:45, I got my first cut; by 10 am, I had a 2 min 29 sec version of the song loaded onto my iPod. Thank you David..and Steve Jobs. Technology is truly amazing.

On people: After looking at more than 1000 dresses on line (yes, 1000), my favorite was a lace and crystal extravaganza made by Randall Designs. Custom made for L'il Kim (the rapper) when she danced the Argentine Tango on Dancing With the Stars, the dress is for (re)sale, but the price tag...excessive. As a last resort, I asked Randall Designs if they could help me and explained the charity. To my surprise, they graciously agreed to let me borrow the dress for the night. Generosity is abundant.

On health: By itself, dancing once or twice a week hasn't been rigorous enough to get me in shape. But, the pressure of a performance has suppressed any desire to binge, got me back on the treadmill and motivated me to lift weights every day. The result: I'm a little lighter and a little firmer (for now) with greater appreciation for the power of the accountability that arises from publicly stated goals. Competition is an important element of behavior change.

On purpose: Many of us receive donation solicitations and dutifully write our checks to various charities. However, in this case, complementing the financial support by getting personally engaged has connected me to the cause and touched my heart in a way I didn't expect. Whether you are passionate about breast cancer, a religious institution, a political candidate, human rights, or legal advocacy....immerse yourself. You will get back much more than you give. Philanthropy is more meaningful when you give of yourself..not just your money.

On human rights: During a recent tour of the CornerHouse, my spine shivered when I learned that in the room next door, a young girl was disclosing the details about her sexual abuse. This story repeats itself 3 times a day...every day. Child abuse is real.

And so many more.

So, as hard as it is for me...I will "just ask" if you would support the children served by CornerHouse by voting for your "favorite" dancer. Here is the link. Each vote costs $5. You can buy as many votes as you want using the online link below. I would greatly appreciate it.

Create Health,

Archelle

Dancing With The Boogeyman

2011-08-23T10:02:00.000-05:00

A report of child abuse is made every ten seconds and three million cases involving almost 5.5 million children are reported each year. This tragedy occurs at every socioeconomic level, across ethnic and cultural lines, within all religions and at all levels of education.

This issue has never impacted me, my family or anyone close to me, but since childhood, I have been passionate about protecting children from abuse. As early as age ten, I was in Rock Creek Park (in Washington, DC) on a picnic with my family when I saw a mother whipping her young children with a tree branch. I marched up to her and demanded that she stop. As recently as a month ago, while patiently waiting for a table at IHOP, I noticed a mom yanking so hard on her toddler's arm that she was pulling her up from the floor. "Um...excuse me," I said calmly as I kept texting on my phone, "but if you keep doing that you might dislocate her shoulder." She stopped yanking then and angrily tried to defend herself. I stayed within her striking striking distance and secretly hoped that she'd hit me so that I could call the police...and protect an innocent 2 year old.

In this month's Martha Stewart Whole Living Magazine, I was interviewed about child abuse and it's impact on adult medical illnesses. I was familiar with the association between early abuse and conditions such as depression, fibromyalgia, irritable bowel syndrome, and eating disorders, among others. However, it was only because of a smart journalist's leading question that I learned about the epigenetic impact of early abuse. Stated simply, environmental events and exposures impact whether genes are turned on or off.

According to the Center on the Developing Child at Harvard University,

"If young children or pregnant mothers experience toxic stress as a result of serious adversity (such as chronic neglect, abuse or exposure to violence) in the absence of protective relationships, persistent epigenetic changes can result. These modifications have been shown to cause prolonged stress responses....(which can) result in increased risk for physical ailments, such as asthma, hypertension, heart disease, and diabetes."

CornerHouse is a non-profit agency in Minneapolis that works closely with law enforcement, child protection, and the county attorney’s office to advocate on behalf of abused children. Each year, their annual gala, "Lets Dance" is modeled after the show, Dancing with the Stars. Six local celebrities (Minneapolis business executives, community leaders or social figures with key contacts who can help raise visibility and money for the event) are paired with a professional dancer and dance studio who donate 15 lessons. The performance is a fully choreographed, three minute performance with the "winners" being the pair who dance the best and raise the most money.

When I was asked to be one of the local celebrities for their November 12, 2011 event, it seemed like a no-brainer. I care deeply about the cause, have decent rhythm and have always wanted to take dance lessons. I am not afraid to be on a stage, the chance to exercise is always a plus and, of course, I'd get to wear a fabulous outfit. Even before meeting my dance teacher, I decided to do a Latin dance since the music and fast-paced beats were similar to the Greek music I'd grown up with.

Bruce Abas at Four Seasons Dance was selected as my dance teacher and partner. He is a perfect fit since he'd studied Tango in Argentina and Salsa in Puerto Rico and Cuba. At the first lesson, we briefly introduced ourselves to each other, and then Bruce quickly launched into demonstrating the Latin Basic and the Side to Side steps while we both stood in front of the mirror. "Got it! This will be easy," I was thinking to myself.

After thirty minutes, it was time to practice the same steps while dancing together...facing each other. And, that's the last time this experience was easy. It was frightening.

In order to do any ballroom dance properly, it is essential for partners to communicate with direct visual contact, arm resistance and close body contact. In addition, Latin dance requires a sensual movement of the hips in order to make it authentic and beautiful. A basic rule is that the male partner is always in control. And, finally, trust is essential.

Try this with a relative stranger. Try this when your success has been centered around the rules, mores and conservative behaviors of corporate America. Try this when you have led your whole life being "in control." Try this when the skeletons from your past are sending you conflicting messages and fueling a heightened stress response.

Lessons two and three triggered the same fright and anxiety. I contemplated backing out, and one friend suggested that I simply write a large check and withdraw. But, it's my husband who encouraged me to follow through. In fact, not only has he encouraged me to dance well, but to dance with the emotion that it will take to win. Besides honoring my commitment to CornerHouse, it is a personal opportunity to grow.

I have had my 5th lesson and can finally make eye contact with Bruce. I can even do a few turns. The hip thing is still a problem, but improving a little. While Bruce is in control of the dance moves, I am finally feeling in control of my Boogeyman.

Take home message: Don't run away from yours.

I will periodically continue to blog about this experience as we lead up to the November event.

Create Health,
Archelle

It's Just Coffee

2011-08-17T07:22:00.005-05:00

There has only been one moment of levity on Wall Street in the last 2 weeks. It was Friday, July 29 when the Smurfs rang the opening bell at the New York Stock Exchange. Smurfette, the one on the left with yellow hair, is my daughter, Arielle. Her fifteen minutes of fame at the Exchange was a few days after being with Katie Perry and Brooke Shields on the "red" (actually, blue) carpet at the movie premiere. On that day, the actresses had on couture clothing and bling while Arielle was dressed as...Papa Smurf.

How does a 21 year old get to hang out with movie stars and then get VIP treatment on the floor of the Exchange? One could simply write it off as a benefit of living in New York City...or being at the right place at the right time...or, my least favorite, being lucky. On the other hand, one could attribute her experience to a willingness to take a calculated risk.

When Arielle agreed to this opportunity, she didn't know what any of the perquisites would be. Being a Smurf doesn't quite meet any of the typical criteria for opportunities that might advance her education--she is an International Relations major and law school bound without any hint of acting/theater aspirations. The only information she had was that she'd be running around New York City during a heat wave wearing a heavy blue outfit and getting paid $100 for each event. Nevertheless, it sounded fun...she had the time...it was safe, and it was legal. (Yes, I am grateful that it met all three criteria.)

It's easy to identify an opportunity when it is presented as a promotion, attached to a salary increase and packaged into a press release with corporate fanfare. But, how do you recognize those subtle moments when a door gently opens...just waiting for you to walk through it? It's not luck. It's a process.

Here are a few tips that have served me well. They combine a little intuition with an intense commitment to developing relationships.

1) Listen to your gut. Don't over-analyze. In mid-2008, Dan Buettner, author of Blue Zones, didn't have the name recognition and fame he has today. But, when he jokingly invited me to participate in a longevity expedition to Greece, I immediately called my husband, and told him I'd be away for 3 weeks. Given my diva approach to vacations, I knew that I'd never have another chance to experience Greece with a rugged explorer. Spontaneous? A little. A calculated risk? Absolutely. The trip sounded adventurous and I had the time. I didn't ask too many questions about safety; since I speak Greek and have a credit card, I figured I could get out of any untoward circumstances. Little did I know that this experience would fundamentally transform my view of health and health care in addition to fueling a myriad of speaking and media opportunities.

Pay attention (!) if you have an initial fleeting thought of "That's really interesting" or "I'd love to do that sometime" or "Wow...that's a once in a lifetime opportunity." Look for ways to take advantage of new experiences instead of ignoring your piqued interest and/or getting paralyzed by over-analyzing barriers.

2) Take the cold call and listen. Mickey Beyer-Clausen, CEO of Mental Workout, found my cell phone number and called to introduce himself. No referral. No e-intro from a mutual colleague. It was tempting to say, "Sorry, I have no time," but instead, I took my own "how to" advice, risked 5 minutes and listened as he explained that his company was reinventing psychology with mobile applications. Within a few minutes, it was clear that he had an innovative and disruptive health care technology. Eight months later, not only have we forged a formal business relationship, but Mickey also introduced me to a company (now a client) with groundbreaking innovation around hospital-acquired infections. (More on that in a future blog.)

We all receive our share of unsolicited calls. Talk to every single one; engage in the conversation for long enough to make an informed decision about the potential synergy with the caller. The calculated risk is miniscule: lose some time versus lose a chance to participate in meaningful change.

3) Carry your business card. Meet for coffee. Don't show up with an agenda. Introductions occur every day...at work, the health club, at dinner parties, in the grocery store aisle. With a few, there will be an immediate connection. Why? Who knows? There isn't enough time or interaction in the 7 second "meet and greet" to figure it out. However, if you simply walk away, you are likely to lose the connection forever. Hand them a business card, get their contact information, send a follow up note and arrange to have coffee. (Note to self: Pay for their coffee.)

Has a colleague, a friend, or a relative proactively offered to introduce to one of his or her contacts? Never, ever turn them down or procrastinate for so long that the opportunity passively vanishes. But, what if the individual is outside of your industry, your educational/professional background, or (gasp) above or below your grade level? What if you can't see an obvious link between what you do and can't think of a business reason to meet with them? Don't pre-judge; don't speculate. There is no risk if you are genuine and don't expect anything in return. Just show up, learn everything about what they do and, if there is time, take a few moments to tell them about yourself.

To many, it may seem like an extraordinary time commitment to meet or talk to virtually every individual who suddenly appears in your world for the mere handful of conversations that might materialize into a valuable or profitable interaction. But, there is more than that. With each conversation, you get smarter and expand your potential as you are introduced to a new thought, a new industry, a new perspective, or a new cause. In the article, How Aha! Really Happens, the authors describe a concept the concept of intelligent memory:

"From the moment you're born, your brain takes things in, breaks them down, and puts them on shelves. As new information comes in, your brain does a search to see how it might fit with other information already stored in your memory. When it finds a match, the previous memories come off the shelf and combine with the new, and the result is a thought. The breaking down and storing process is analysis. The searching and combining is intuition. Both are necessary for all kinds of thought. Even a mathematical calculation requires the intuition part, to recall the symbols and formula previously learned in order to apply them to the problem. When the pieces come off the shelf smoothly, in familiar patterns — such as simple addition you’ve done many times — you don’t even realize it has happened. When lots of different pieces combine into a new pattern, you feel it as a flash of insight, the famous “aha!” moment."

That's a pretty good return-on-investment for the price of a cup of coffee.

Create Health,
Archelle

Chinese Takeout: 3 Impressions I Carried Out of China (and Vietnam)

2011-07-20T10:02:00.000-05:00

"So, how was China?"

We recently returned from China and Vietnam and have been asked this question many times by curious friends, family, and colleagues. Recognizing that we live in a world of soundbites and that no one really wants to hear every detail about our fourteen day trip, I've responded by focusing on the experiences and observations that had a lasting impact on how I think. There were three: one is personal, one is political, and one is professional.

Shanghai: Freeways with neon blue underlighting amidst skyscrapers

Personal: While "Made in China" is present on everything from chatchkas to clothing labels to housewares, and although China's thriving economy is a frequent topic in the business world...I simply wasn't expecting to see their ultra-modern infrastructure. I went to China with a visual image that was pre-Mao. Shame on me. Instead, I saw 14 story shopping malls, a Shanghai skyline best described as "New York on steroids," an efficient and clean subway system, and construction cranes on every square block. While analysts predict an economic and building bubble that will deflate soon...there is national confidence that China's 5 Year Plan (for 2011-2015) will address these risks. Take a look at the well-defined, measurable goals regarding their economic targets, innovation, the environment, people's livelihood, social management, and reform. The Plan is translated into action down to the individual citizen level to assure that they achieve their goals. We may not agree with socialist/communist ideals, but step back for a moment and imagine how much progress the US would make if we had a unified plan regarding our nation's advancement.

How was China? A strong world power. Never again will I refer to China as an "emerging economy." They have emerged, and there are a few things that the US can learn from them.

600 people live on floating platforms in Ha Long Bay, Vietnam

Political: In Vietnam, our guide whisked us to Ho Chi Minh's tomb, and proudly announced, "We are a communist country." Well versed in his country's history, Happy (yes, that was really his name) gave described, in depth, how communism liberated the Vietnamese from the French. As usual, we peppered him with as many questions as he would tolerate about life in, what we presumed to be, a classless society. He was understandably cautious in how he represented the government, and his standard response to many questions, such as "How much corruption is there?" was "That is a sensitive question that I cannot answer." Recognizing there are pros and cons to any ideology, we looked forward to hearing about their health care system and how it was designed to offer equitable access to care. We were shocked when he explained that only those who have money can afford health insurance, and only those who have insurance get health care. Everyone else struggles. I was distraught. "What?! How can this be? How can a fundamental need not be provided in a communist country?" His response? "That is a sensitive question that I cannot answer."

How was Vietnam? Physically beautiful but politically contradictory. I have since learned that Vietnam (and China) have a "socialist market economy"--in other words, they have both the political and social disadvantages of communism as well as the economic disadvantages and disparities of capitalism.

Great food, but we just wanted some rice!

Professional: During the annual business planning cycle of US businesses, it is typical for managers to request a budget to hire more staff. In most cases, the proposed employee increase is trimmed, slashed, or completely eliminated with subsequent grumbling about the "impact on service and innovation." Sound familiar?

While we were in China, I paid particular attention to staffing. In a nation with almost unlimited opportunity to hire due to low labor costs, I paid special attention to whether more people resulted in better service. My observations were far from a formal analysis..but, here's what I saw:

Staffing levels were 3-4 times higher than in the US. Example: In a casual US restaurant, there is typically 1 host who greets and seats customers. In China, there were 4:

At the entrance to the restaurant. Responsibility: open door
In front of the hostess stand. Responsibility: ask for number of people in the party
Behind the hostess stand: Responsibility: assign the table
Beside the hostess stand: Responsibility: lead guests to their table

The service was adequate (but not extraordinary) as long as we had ordinary, predictable requests. But, when we strayed from the norm---service collapsed. When we tried to order a plain bowl of rice for Zoe in a restaurant with rice-based dishes, we created a bit of chaos. The waitress called the supervisor who called the manager. After fifteen minutes of huddling, they were unable to serve a plain bowl of rice since it wasn't specifically listed as a menu item. An overflowing chafing dish of plain rice was 20 feet away in the buffet line. We gave up.

This scene, with different details, was repeated multiple times each day. (No, we were not being difficult Americans.) While our daughter lived in Shanghai, she was in the bed/mattress section of a department store and asked where she could find bed pillows. The bed salesman had absolutely no idea...and was unable to help figure it out.

The employees did not seem are complacent, uncaring, or intentionally inflexible. Instead, they just couldn't think or act outside the boundaries of their tiny, narrowly defined scope of responsibility. I realized, for the first time, that excess labor isn't necessarily a solution to better service. Rather, it can drive inefficiency and dilute accountability for the entire consumer experience.

How was China? A culture that fosters order and compliance versus risk-taking. Yes, they can copy couture fashions before they are off the runway, and reproduce the newest Apple device before Steve Jobs is off the stage, but the lack of flexibility and, consequently, little problem solving, translates into a larger national issue for China: lack of innovation. The government, however, has recognized this risk, and the 5 Year Plan includes investments in R&D with a goal to achieve 3.3 patents per 10,000 people.
What was my overarching takeway, or, should I say takeout? Our trip was analogous to a Chinese feast that offers a disparate array of exotic foods that I never imagined eating. Similarly, our trip offered a disparate array of impressions and observations that disrupted some of my long held beliefs. I am still digesting it...though with a little heart burn.

Create Health,
Archelle

The Battle Over Avastin

2011-07-01T11:04:00.003-05:00

The use of Avastin for breast cancer was addressed by the U.S. Food and Drug Administration this week. The outcome was devastating for Roche and an emotional one for many women who believe the FDA is subjecting them to a death sentence. As usual, there are a variety of perspectives to take into consideration.

The history: In 2008, Avastin was given preliminary approval by the FDA for the treatment of breast cancer on the condition that the company would do more studies to demonstrate its effectiveness. Many women have been successfully treated with Avastin -- a billion dollar drug for Roche.

But when Roche submitted the required follow-up studies in 2010, the data showed that there was no benefit from the drug for treating breast cancer. Studies did not show significant impact on mortality or improvement in quality of life. In addition, the drug was associated with some significant side effects such as high blood pressure and blood clots.

In December, 2010, an FDA panel voted to withdraw the drug's approval as a treatment for breast cancer. Roche appealed the decision, and earlier this week, an FDA panel hearing the appeal unanimously decided, in a 6-0 vote, to withdraw the drug's indication for breast cancer. The final decision on whether or not Avastin loses the indication is ultimately up to the FDA Commissioner, Dr. Margaret Hamburg.

Hamburg support of the panel's recommendation is critical. At the same time, this will fuel even more emotion and protests among patients. Here's why:

• From the FDA’s side: The FDA issued a provisional approval with the explicit understanding that the final decision would be based on more conclusive studies. If the FDA maintains the drug's approval despite the lack of scientific data, this would likely impact all of their future decisions to offer provisional approvals for potentially life-saving drugs.
• From the patients' side: Women who have benefited from the medication have clearly voiced their opinion that the doctors and patients, not regulators, should decide whether or not to get potentially life-saving treatment.

An important fact to keep in mind is that Avastin will remain on the market because it is FDA-approved for certain types of lung, colon, kidney and brain cancers. Therefore, Avastin will still be available "off label" for treating breast cancer when patients and their doctors believe that this medication is the best option. In those situations, the only real barrier to access is financial since expensive drugs used "off-label" are frequently not a covered benefit, and very few women can afford $80,000 per year out of pocket for Avastin.

Roche is understandably passionate about making this drug available to women, and they will be pursuing additional studies to prove its effectiveness. But, in the mean time, there is a solution that's not been discussed and doesn't involve beating up on insurance companies: For women who decide (despite the data) that they want or need Avastin, Roche could simply decrease the cost.

What do you think?

Create Health,
Archelle

Sources:
FDA begins process to remove breast cancer indication from Avastin label
www.fda.gov/newsevents/newsroom/pressannouncements/ucm237172.htm

A version of this blog was originally posted on EmpowHER.

Mayo (Clinic): The Secret Sauce To Better Care

2011-06-15T09:06:00.000-05:00

“In the event that I have a critical illness and am unable to make medical decisions for myself, my health care agent, David Feldshon, should transfer me to Mayo Clinic for health care services as soon as I am stable for transport.”

This is the exact language included in my Health Care Directive. No, I have never been a Mayo patient, don’t have any medical issues and don’t plan on getting sick any time soon. Nevertheless, I simply feel better knowing that if I need critical care, I will be at an institution where I believe I’ll have the best chance of a good outcome.

The aura that surrounds Mayo has mesmerized many. Friends and colleagues who have trekked to the Clinic for their $5000 executive physicals have uniformly reported that after being poked, prodded, and palpated for two days, they felt reassured that they'd had a thorough evaluation. And, of course, there is a continuous stream of royalty and dignitaries who fly their private jets to Rochester to get, what they hope, is the best care in the world.

But, are these beliefs, hopes and perceptions real? Do Mayo doctors really offer better care or does the institution just have a better, and incredibly powerful, brand?

Last month, I got closer to an objective answer. I was invited to give a keynote speech on health, longevity and technology at the Mayo Clinic Alumni International Meeting in Athens, Greece, and I attended two days of the conference. Of the 150 attendees and speakers, I was the only one who was not a Mayo graduate and/or a practicing Mayo doctor. But, as the sole outsider, I had a unique glimpse into their world.

Mayo hosted a black tie dinner in a swanky restaurant on the shores of Vouliagmeni Beach. In the midst of the glorious sunset and a gourmet meal, Dr. Scott Swanson, one of the Scottsdale-based urologists, turned to me and said, “Ok, Archelle…you challenged our conventional thinking earlier today. Challenge us some more. Throw out some tough questions.” I couldn’t resist the invitation to ask: “Do you really believe that Mayo offers better care…or does Mayo just have a great brand. And…why?”

I expected an immediate, and arrogant, “yes, of course we provide better care.” This is the typical response I’d received in the past from large multi-specialty groups who defended their clinical superiority based on the size of their practice, patient volume, number of procedures, and income. Instead, the conversation at the dinner table focused on how Mayo's environment facilitates better care and a better experience for patients. Initially, they pointed to two key elements of their system:

1) Electronic Health Record: Mayo’s EHR was designed and built in-house, and the physicians uniformly agreed that it is organized to be useful for patient management--not simply a vault for medical record documentation. As a result, their EHR is a key enabler of efficient communication between doctors and staff regarding diagnostic workups, treatment plans and follow up visits.

2) Immediate Specialty Consults: There is significant peer pressure among the doctors to be highly accessible. If a doctor has a challenging case and needs a specialist to assess their patient, there is an expectation that colleagues will make themselves immediately available. “Too busy,” “later” and “can’t do it today” are shunned and not part of the vocabulary and relationship that doctors have with each other. As a result, they believe that complex diagnoses that take weeks or months to sort out in other settings can get addressed quickly and efficiently in the Mayo system.

Dr. Swanson was clearly enjoying the conversation but wanted more controversy. He presented a specific patient care issue: “Would you do prostate cancer screening on an 80 year old man?” (FYI, the US Preventive Services Task Force guidelines recommend against PSA screening in men age 75 years of older.) A spirited debate erupted, and I pulled out my notepad:

Medical oncologist: "No, it's unlikely that screening would make a meaningful difference in the patient’s outcome."

Dr. Swanson: “That’s an insurance approach to the patient. What if the man’s parents died at age 95 and there was no other underlying illness? If you found a cancer, you could potentially let him live out those 15 years.”

Medical oncologist: "Agree...but there should be a discussion with the patient in advance of the testing to explain the implications and potential treatment associated with a high PSA result."
Family practitioner (wanting to get in on the debate): "What about a 40-year-old man whose father and two brothers all died of prostate cancer? I screened him and ended up diagnosing a Gleason 2 (early stage) cancer. This guy is likely to be the only male in his family who will survive past the age of 65."

While each of the Mayo doctors started with slightly different clinical approaches, they shared a common philosophy: guidelines are just that--a guide; treatment should be personalized based on the specific needs and circumstances of individual patients. In addition, there was a striking absence of CPT codes, insurance rules, or reimbursement opportunities influencing their judgment. And, in striking contrast to doctors in private practice who tip toe around each other to protect referral patterns, the Mayo docs clearly felt comfortable challenging each other when they disagreed. I suspect that it is this type of collegial banter that results in the thorough and coordinated care plans for Mayo patients.

I probed further and kept firing questions. I shared the story of a friend who had a positive experience at Mayo but had a difficult time getting follow up questions answered over the phone. The internist spoke up: “Most processes work well, but there are still issues we need to address. We need to make sure it’s easy for patients to get their questions answered.” No defensiveness. No rationalizing. No whining about reimbursement rates as the barrier to being responsive to patients.

This was Mayo's secret sauce. They have a culture of “patient-centered care.” The aspiration of many. The achievement of very few.

Last month, Mayo launched its first affiliated practice network (APN) relationship with Altru Health System in Grand Forks, North Dakota. This is a strategy to broaden Mayo’s footprint without building new, owned facilities. Health system who are part of Mayo's APN maintain their independence but have fast track availability for consults and immediate phone access to Mayo specialists. Mayo will share its electronic health record system and clinical protocols—as well as it’s coveted brand.

This is a brilliant strategy but only if Mayo develops a deliberate and effective plan to also export its secret sauce. Will doctors in these more loosely organized health systems be committed to being available and accessible for each other? Will they feel safe to debate? Will they make and take the time to collaborate and coordinate integrated treatment plans? Will they take a multi-disciplinary view toward patient care without protecting their small kingdoms and personal income? Will they learn to care about the patients’ experiences? I don't mean to imply that all other health systems are starting from ground zero, but the Mayo brand implies a solid and consistent patient-centered culture.

The real question is whether establishing a patient-centered culture is even possible in a production-driven, fee for service health care systems. Time will tell.

In the mean time, David, my health care agent, has strict instructions:
Do Not Pass Go. Do Not Get $200. Take me directly to Rochester.

Create Health,
Archelle

To Sell Your Story, You Have To Tell Your Story

2011-05-25T02:27:00.001-05:00

It’s great when the stars align:

The Wireless Life Sciences Alliance Summit was in San Diego.
Michelle King Robson, CEO of EmpowHER (and a dear friend) was a panelist/speaker.
Michelle and Ed Robson's boat is docked in San Diego harbor.

The Robson's graciously invited me to stay with them on their 120 foot yacht instead of staying at the Hyatt. Ummmm...okay. As you might expect, it was amazing. But, I will forego a description of the boat's luxury and the 24/7 attentiveness by their staff because the most memorable part of staying on this beautiful vessel was the time I spent with Ed each morning over a few cups of Starbucks coffee.

A little about Ed Robson: Adopted. Graduate of Colorado College. He joined the Marines and was helicopter pilot but then got a leave of absence to play on the US Olympic Hockey Team. Ed started his career selling real estate then started his own real estate company and then started building homes. Forty-five years later (Ed is a vibrant 80!) he is the owner of Robson Resort Communities, a collection of 7 adult active senior living communities in Arizona and Texas. He also owns 100+ additional companies that control the entire supply chain....from water to carpet for the 40,000 homes he’s built. In other words, he owns seven small cities. Its fair to say... he's had a very successful career.

Ed walks his three dogs at 5:45 am. Since I was on a different time zone and awake before sunrise, I quickly figured out that I could find him on the back deck of the MyChelle by 6 am. I tried to extract as much wisdom as I could from his brain. The topics of our conversations ranged from from health, seniors and fly-fishing to architecture, wealth, and raising children to be accountable. I asked Ed countless questions. He was gracious, humble, and, frankly, tolerant. But, it was his answer to the most probing and personal question that inspired this blog.

"Ed, is there anything about your career that you regret?" He paused, and I expected him to talk about a failed real estate deal or a missed business opportunity. Instead, he said, "I wish I had been a better student and got more of an education."

He explained, "When I was in a room with these business guys from Harvard or Yale...they weren't more intelligent than me, but they got their ideas out better and faster. And, in those high pressure meetings...there isn't alot of time to listen. So, those guys would win."

Ed’s laser-like answer wasn’t referring to education as a way to get more book smart but rather, as a vehicle for learning how to be an effective and influential speaker. And, I started wondering…what is the relationship between education, communication, and success?

No one can argue with the value of higher education. There is ample evidence that it is correlated with a broader array of opportunities and greater income potential. In addition to acquiring raw, core knowledge, the learning process, particularly in post-baccalaureate programs, is designed to teach students how to research, analyze, summarize and weave pertinent facts into a compelling, influential argument. Throughout their curriculum, law students are repeatedly required to present briefs, MBA students share their analysis of company studies, and PhD candidates defend their research. With each experience, they get a little smarter and, simultaneously, their communication skills gets a little sharper.

Looking back on my own experience…Morning rounds at John Hopkins Medical School were like a daily Toastmasters exercise. Chief residents expected a crisp, three minute summary of each patient we had admitted during the previous night on-call. No notes allowed. They relentlessly critiqued our presentation skills as much as our diagnostic skills. After 2 years of clinical rotations and 3000 patient presentations later, I graduated with a proficiency in storytelling. (And an M.D.)

While a rigorous academic environment can help fuel and develop strong verbal skills, we’ve all met plenty of professionals who aren’t effective speakers and, conversely, non-professionals who are quite eloquent. The common denominator is neither education nor natural talent. Rather, it’s about practice AND the realization that the story you tell about yourself, your company, your product, your idea--- is highly influenced by Words That Work: It's Not What You Say, It's What People Hear—the best-seller written by Frank Luntz.

Presidents and politicians are judged heavily on their oratory skills rather than their judgment. During my years at United, there were countless times when our capabilities were superior, but how we delivered our story was weaker…and we lost the deal. Clients can really only assess what they experience…and that is you. Therefore, effectively communicating a compelling story that captures mindshare…also captures wallet share.

In my consulting, I typically work with businesses and their executives who have very cool health care technologies or service offerings with significant potential for growth. But, they have challenges telling their story. They are bright, entrepreneurial, and knee deep in content knowledge and product details. But, they don’t spend enough time (and understand the value of) selecting the right words, architecting messages, identifying anecdotes, mining key data points, developing beautiful slides, practicing, practicing more, and then listening to themselves tell their company's great story.

I scratch my head when a senior executive says “I do better when I am spontaneous” and convinces themselves that they don’t even have to prepare key messages before a presentation. I am amazed when sales teams are unleashed in front of clients without being required to deliver the pitch internally to get some feedback. The most common excuse: It’s intimidating. Really? Is it scarier to speak in front of a client representing a multi-million dollar opportunity versus your boss? If that's really true, then turn on your laptop camera and start videotaping. Play it back, critique yourself, then practice again. And, again. That’s what it takes.

All things being equal, those who practice more and learn to communicate better…win.

Create Health,
Archelle

PS: You can't delegate the practicing to your marketing director. Doesn't work.

“Healthcare” versus “Health Care”: The Value of a Space

2011-05-11T07:39:00.002-05:00

There have been several blogs and articles written on the grammatical appropriateness of “health care” versus “healthcare.” In Michael Millenson's post on The Health Care Blog, he explains that the Associated Press (AP), which dictates journalistic style standards, says the correct usage is “health care.” Two words. Most major journals, newspapers, and media sites follow this convention, but it may not be the end of the debate.

There is an equally accepted convention that says that “health care” is correct when there is reference to a provider’s action, and “healthcare” is used when it is an adjective to modify another noun or verb—healthcare system or healthcare marketing—for example. And, there are many sites that shift, very consistently, between these two approaches depending on the sentence structure.

I can live with 2 different literary conventions … but here is what is keeping me up at night and: literary styles change.

“Airline” used to be “air line” and “website” was formerly “web site.” Similarly, there is pervasive evidence that the “health care” is turning into “healthcare.” In my own cursory review of sites that I respect--WebMD.com, Kaiser Family Foundation, the Institute of Medicine, I found that "health care" and "healthcare" are used interchangeably without grammatical rhyme or reason.

So, why do I care? And, why should you care that the adjective, “healthcare,” is well on its way to becoming a noun or a verb? In fashion, style changes drive revenue. On Twitter, eliminating the space creates capacity for one more character. However, in health care, eliminating the space and turning two words into one, will have a negative impact on people, their well-being, and thereby, worsen an already deteriorating system.

Take a moment to do an experiment:

1) Write the following sentence on a piece of paper:

Healthcare is important.

2) Show the paper to a few different people, and ask them to explain what the sentence is referring to when it says “healthcare.” Listen for the meaning they ascribe to the word "healthcare."

What is the first thing they say? Most likely, they refer to insurance, access, costs, and/or health reform. Do any even refer to the quality of care that they receive from doctors or other care providers? Do they refer to the importance of their own lifestyle behaviors? Probably not. In my experiment en route from Minneapolis to San Diego yesterday, with an n=5, only XX said anything about care, and only as an after thought.

The explanation is pretty straightforward:
Language triggers images.
Images stimulate thoughts.
Thoughts motivate behavior.

The word “healthcare” conjures up images about the system---not doctors or nurses; not medications; not nutritious foods or exercise. As a result, a gradual, seemingly innocent, linguistic transition to ”healthcare” may slowly erase our mental images of wellness and fuel an unconscious passivity among patients and clinicians regarding their personal accountability as individuals and professionals. The result: further deterioration in the nation’s health.

In the middle of writing this post, I realized that I am contributing to this unfortunate, literary transition. The tagline for Georgiou Consulting is “Healthcare…Simply.” I am embarrassed to admit that when I went through a branding process and web site design in 2009, I worried about the font and the colors and didn’t even think about the broader implications of using one word versus two. So, I will change it (Ka-ching!) and, consistently change how I write.

So, what can you do?

Take responsibility for the word(s) that you use in memos, letters, emails, tweets and other content that you author. Hit the space bar between “health” and “care.” Each time you do, you’ll add value to someone’s life by triggering an image … stimulating a thought…and motivating a behavior.... that has the potential to make a positive difference.

Create Health,
Archelle

ACOs: Millions of Web Hits…Dozens of Theories…One Bottom Line

2011-04-19T12:59:00.002-05:00

9 million. That’s how many web hits are returned during a Google search for “Accountable Care Organization,” and reflects the countless articles, white papers and opinions that have been published regarding the potential successes and more likely pitfalls of the proposed ACO mandate. As highlighted in TripleTree's recent post, our team is continuously evaluating the business development opportunities being fueled by the demands and requirements of these new provider organizations. Last week, the members of our Healthcare Executive Roundtable recently discussed and debated an element of the ACO equation that is not typically highlighted but is clearly a critical component of ACO success (or failure)…Trust.

In boardrooms around the country, health care executives are focusing on the technical requirements for their future ACO’s clinical and administrative systems. They are pouring over spreadsheets and attempting to understand the data and analytical tools that will be necessary for adequate financial and quality of care reporting. Getting these operational elements “right” is important; however, these business leaders should also focus on designing a culture – and the corresponding behaviors, communication, and incentives that will fuel strong and collaborative relationships between the ACO and its community of providers.

As Ed Brown, CEO of Iowa Clinic puts it, “People are unclear about what the value-based world looks like, and they’re unsettled on what clinical integration really means. And nobody has really made it work.” This lack of clarity around the value-based model will make it challenging for providers to leave the financial security blanket of the traditional fee-for-service payment engine. Moreover, influencing them to modify their approach to patient care for the benefit of the system and the promise of shared savings is a monumental effort. Success by any measure will largely depend on the trust established between providers and the ACO organization itself. ACO’s should prioritize establishing trust with providers in three key areas:

ACO Operations and Management: Providers need to trust that the ACO is well run. Understanding the organizational governance, expertise of the management team and core capabilities (strategic assets) will help generate confidence that the ACO is well-positioned to generate enough shared savings to make participation worthwhile. In addition, it is critical that the ACO measure and report management performance metrics that demonstrate its accountability to the providers.
Compensation Incentives: Providers need to trust that they are getting their fair distribution of shared savings. Clinical algorithms defining quality and outcomes must be evidence-based; and the financial tools and risk-adjustment methodologies used to distribute payment must be easy to understand. Above all, the organization’s compensation schemes must be highly transparent and accessible so that providers can validate that they are being treated as an equally valued business partner in the organization.
Confidence in Provider Team: Providers need to trust their ACO provider colleagues. If the right incentives are in place to bring members within the organization together, providers will need to trust that their peers will also be active participants working toward fully coordinated care within the ACO. Under an accountabilities and outcomes-based model, it will be important that providers view their care responsibilities as extending beyond the encounter. Active provider participants should be practicing first-class follow-up care, improving patient satisfaction, and reducing re-admission rates which will achieve collective rewards.

The inclusion of ACOs as a provision of the Patient Protection and Affordability Act is a strategy to realign delivery systems in the US so that they provide high quality, coordinated care. The bottom line for achievement might simply boil down to whether providers can engage in meaningful and integrated relationships with the ACO and with each other. Since relationships are based on trust—predictability, integrity, and reciprocity–it is imperative that ACOs make trust a deliberate priority.

This post was co-authored by Archelle Georgiou and Emma Daugherty, Senior Analyst at TripleTree and originally published on the firms blog site, Uncommon Clarity.

Create Health (not just wealth)
Archelle

Bill McGuire on Wireless Health and Technology

2011-04-07T12:26:00.001-05:00

The following article was originally posted in mobihealthnews by Brian Dolan.

McGuire: The Land Grab is Misguided

The former chairman and CEO of United Health Group Dr. Bill McGuire recently discussed the opportunity for wireless health (or technology enabled healthcare or whatever you want to call it), wasteful spending on EMRs, the need for interactivity among healthcare technology applications, opera, education and much much more. Dr. McGuire is the Vice Chairman of TripleTree Holding Company and is delivering one of the keynotes at the upcoming Wireless-Life Sciences Alliance Convergence Summit in San Diego next month. TripleTree is an investment bank and one of the founding members of the WLSA and the summit.

Read on for an edited version of our recent conversation with Dr. Bill McGuire.

How do you characterize the opportunity for wireless health? Could you also provide us with some sense of the current investment climate — a lot of activity? A lot of interest but not a lot of activity?

I like to position it as: How can we build products, services, and systems that facilitate the eventual appropriate health and wellbeing for the people in this country and elsewhere. In pursuit of that and in consideration of all that has been done — both good and bad — and all that is yet to be done, which is significant and formidable, I think the whole area of technology enabled healthcare or mHealth or any term you’d like to apply, offers significant opportunity to meet that end. It still remains to be seen obviously what the most appropriate areas and most beneficial areas will be to accomplishing that. When it comes to investments, of course, there will be a lot of investments in things that don’t make any difference or are not contributory to the kind of outcomes I am describing.

What kind of things?

If you look at what has happened in last several years particularly with reform: These huge expenditures that have been directed at technology applications in healthcare. I’m afraid we will see that we have spent an enormous amount of money for marginal or no gain. It’s very indiscriminate. That’s classic healthcare, though and classic investing: ‘Let’s just throw money at things.’
You have the whole idea of applications on cell phones for example. Embedded among [the thousands] of health apps out there are probably a few that will make a difference in the lives of some people. Those apps should theoretically lower costs and improve outcomes, but most of these apps exist because we happen to like apps, it’s a nice story, so we chase them. Discerning what is ultimately going to make a difference and result in the kind of outcomes we are looking for, which is differentiated from just investing money, is the critical issue. The smart investors, smart developers, smart policy makers and so on will benefit from that. The land grab that is going on right now — just throwing money at it — is a little bit misguided.
Another issue is the lack of interactivity among these technology applications. The fragmentation and silos continue. Rather than determining how to piece a number of necessary components together, we have a lot of independent efforts out there to chase after something. We ask for electronic medical records (EMRs) but we don’t necessarily put out standards of performance and interactivity between them. So when someone comes along and asks to gather data or information we know that we can’t get it from each and everyone of them.

So EMR efforts are misguided?

The amount of money that is being thrown at this stuff relative to the value that it is going to return to us is ridiculous and it will not prove to offer up the kind of end gains that we are touting. Those are health outcomes gains and financial gains in terms of lowering costs. I see nothing that suggests this is going to dramatically improve outcomes, improve access to care for people who had heretofore not had access to care and certainly nothing that suggests that it is going to lower the costs of healthcare in America. People are rushing to do various EMRs simply because the government says we will pay you to install it. If you talk to people who try to extract data from various EMRs they would tell you that there is no consistency in the expectation to do it from many different systems and yet we are spending billions of dollars on this.

Let’s switch gears back to wireless health. Are any companies on the right path? If you aren’t comfortable naming companies, what are some specific use cases that you think are promising?

I will be necessarily cautious about the specifics because I don’t want to come across as endorsing or refuting things that I know relatively little about specifically. Let’s start with a concept. What I think we are talking about in some way parallels what we are seeing from efforts in education. As we confront challenges around resource availability and the spacial relationship between the users (the someone in need) and the resource. The ability to take content out to individuals — which is what mHealth or various mobile technologies have done — becomes a substitution for asking those people to go to the content source in a different way.
It’s sort of like: If the cost of gas goes up and bus costs go up, how do we really expect kids to learn about the arts when they used to get on a bus and go on a field trip to a museum? Museums are beginning to take their content to the students where they live. The Metropolitan Opera says we can’t expect everyone to come to the Met, but opera is an important cultural element for society. So they started filming it and showing it at theaters around the country, which has been wildly successful. In these cases we are looking for ways to bring content out to touch people when we can’t in essence do it physically.
In healthcare the same principle exists. People who live in remote sites do not have access to care — primary care to say nothing of secondary or specialized care. How do we help them manage their health and wellness and help deliver services that might be beneficial to acute but relatively everyday problems. That is the kind of application opportunity that the technology provides. Whether that includes telehealth, applications, gaming… that’s the huge opportunity.

Any closing thoughts?

I think healthcare might be unique in that it is a space where technological advance has not positively influenced efficiency or cost reduction. Just across the aboard it has not happened. Costs keep going up year after year after year. Why is that? The discussion we hope to have at the WLSA Summit is around how the companies presenting are in fact going to accomplish the needs of both enhancing efficiencies and lowering costs while achieving improved health outcomes for people. I expect it will be a lively discussion about disruption and how mobile will play into that.

An Apple A Day....Drives Growth

2011-03-28T12:04:00.002-05:00

At 9:55 am on a Wednesday morning. I was 15 miles from home and making good time getting to my 10:30 meeting until I realized that I’d left the power cord for my Mac computer at home. There was no way I’d have enough battery power to get through my presentation. So, I had a choice: turn around, go home and be late or run by the mall and buy a new power cord at the Apple store. Since the mall was only ¼ mile away, I could arrive just as the store opened and likely be the first customer. The decision was easy.

As expected, the parking lot had a scant number of cars and I got a plum spot by the entrance. Racing past several stores en route to my destination, I noticed employees in the sporting goods store dribbling basketballs waiting for their first customers. Gap associates were folding and re-folding jeans while Sephora employees were sampling products and primping in the mirror. The mall was empty.

And, then I got to the Apple store…it was packed. No, this wasn’t the day the iPad2 was being released although the store had already received 200 calls since 8 am from people wanting to know if it was available. What were all those people doing there? Buying Apple products; playing with Apple products, taking classes on how to use Apple products, and getting expert help from the Apple whiz kids at the Genius Bar.

After witnessing this scene, it was no surprise that Apple was in the #1 spot on Fortune’s List of Most Admired Companies in America—again--for the 4^th year in a row. Apple’s wildly successful performance is not new news to any of you; the high level themes are innovation, product, and brand. We’ve read about them many times. But, how can CEO and leaders of companies translate these themes into their business? That’s the diplomatic way to tee up this blog. The real question is: What can health care companies do to be more like Apple?

1. Fit in: In 2008, Apple leaped into the #1 spot in Fortune’s rankings (from #7 in 2007.) Steve Jobs himself said, “Apple products work, and if you buy more than one, they work better.” In other words: integration.

Yes, Apple has a fully integrated platform. But, Apple wouldn’t be as successful without the relationship and integration with Microsoft products. Early on, the company recognized they needed to fit into the prevailing system.

The number of new health care developments that are being generated are dizzying: billing programs to accelerate payment of patients’ copayments; software to maximize performance in pay for performance initiatives, IVR systems that increase patient engagement, incentive programs to enhance compliance with needed behavioral changes. The founders/developers are passionate that their cutting edge innovation will increase “quality and decrease cost.” However, too many of these great ideas aren’t designed to fit into the operational complexities of a hospital, doctor’s office, health system, or payor. And, despite the promise of more revenue and profitability, decision-makers can’t bear to layer any more chaos to an already chaotic system.

True systems integration may be prohibitively expensive for start-up or early stage companies, but at a minimum, be prepared to offer a feasible operational/process solution that achieves integration. How? Roll up your sleeves and invest time in learning how the system is wired: the back office operations in a doctor’s office, the politics of hospital revenue management, the benefits, claim and administration realities of insurance.

2. Sell solutions..not technology. Anyone who’s walked into an Apple store knows that the question the associates ask is: “What do you need to accomplish on your computer?” Fast Company magazine published an article about how Apple employees are hired and trained after one of their contributors worked undercover. The company has a 3-step selling process:

· Position: Understand the customer’s needs.

· Permission: Get permission to ask questions.

· Probe: Keep digging to ascertain which products would be best.

Avoid the temptation to sell your box, your widget, or your innovation. Focus on the customer, the problem they need to solve, and how you can help them accomplish that. Oh…and don’t forget to be intellectually honest. Don’t oversell. Don’t let them buy something they don’t need. In the end, you will sell more and have a loyal client. Bottom line, Jobs says, “When employees become sharers of information, instead of sellers of products, customers respond.”

3. Have a problem? Fix it. Now. In June 2010, sales of the iPhone 4 were so successful that it overwhelmed AT&T’s network capabilities resulting in dropped calls, error messages, and, as a result, negative national media attention. Heads must have rolled at 1 Infinite Loop in Cupertino, but there was relatively little public response from Apple. The immediate issue was quietly resolved and then—WHAM!—in January 2011 Apple unraveled its exclusive relationship with AT&T and announced that service for the iPhone 4 would also be available through Verizon.

How often have you seen heath care companies, particularly the larger ones, try to rationalize away their errors and waste time defending themselves? Claim delays, reimbursement underpayments, customer service issues, regulatory violations, security breeches. Intentional errors? No. Defensive cover-ups? Yes.

We are all at risk for making mistakes. Find them. Acknowledge them. Fix them. Like Apple, pay “meticulous attention to perfection.” Do it with stealth and speed.

Recommendations # 1-3 may be easier said than done. Number 4, however, is simple. It just takes ego strength.

4. Be Steve Jobs: Jobs is the face of Apple. He is the brains behind it’s success. But it wasn’t always that way. Jobs was ousted as the CEO in 1985 when revenues plummeted. While Apple started its turn around when he returned in 1997, the company’s success didn’t sky rocket until about 2006. So, what changed? Jobs. Take a look at 60 seconds of each of these videos:

Circa 1996: Interview. (Watch from :49 to 1:49 to skip introduction)

MacWorld 1997

MacWorld 2006

How many times did Jobs say “I” or “me” in 60 seconds?

In 1996, prior to his return to the company: 13 times

In 1997, within weeks of returning: 5 times

In 2006, 2 times

Don't EVER put “I” or “me” in a memo or a press release. Avoid these pronouns in your presentations. It’s not about you. Although you may be the face of the brand, the founder, the funder, and the brains, your messages should center around the company, the team, and how you add value to your customers.

All that from a $80 power cord.

Create Health,
Archelle

Got Ethics?

2011-03-03T09:14:00.000-06:00

This week's Sunday New York Times had its usual array of breaking national and international news on the front page, but my loudest "Oh No!" came when I turned to page 14 of the Magazine. Randy Cohen, author of The Ethicist, announced that he is retiring his column. For those of you who are not familiar, Cohen's weekly column typically posed two moral/ethical dilemmas followed by his expert analysis and perspective.

This column has been part of our family's Sunday morning ritual since it started being published 12 years ago. Bagels, lox, coffee...and... The Ethicist column. We all knew the routine:

Archelle reads the dilemma. Twice.
Each daughter, youngest to oldest, must take a definitive position and defend it with clear rationale (yes, even Zoe is included in the lineup)
David, then Archelle, declare their positions. (I always go last since I seem to have the strongest opinion and don't want to influence everyone else.)
Family debate...aka...we argue.
Once we're exhausted or reach an impasse, we read Cohen's expert opinion.

This discussion, every Sunday, week after week, was valuable for teaching the girls a process for deciding between right and wrong. The everyday scenarios that Cohen presented were a non-threatening way to proactively work through many of the seductive temptations that they would inevitably face later in their lives.

From December 2002: Is it okay to Google some one you've started dating to check up on them? SN, New York

In 2002, this was a dilemma. In 2011, this seems like a no-brainer.

From May 2004: I am an American posted to Vietnam, where pirated movies on DVD are cheap and ubiquitous, and legitimate copies are nearly nonexistent. Would it be ethical to purchase pirated DVD's if I also join a monthly unlimited-rental service like Netflix? Ben Moeling, Hanoi, Vietnam

Arielle found herself with this exact dilemma as she spends the year in China.

From September 2007: A friend and I will soon take the LSAT. His father, a psychiatrist, gave him Adderall to help him take the test. I asked if he could share some with me, and he said that would be unethical. Is it? Isn’t his dad’s giving him the Adderall unethical? — Name Withheld, Austin, Tex.

The sharing of Adderall on college campuses is rampant.

The lifelong impact of this column became evident in 2005 when Athena was preparing for her Bat Mitzvah and matter of factly announced to us and the Rabbi that she wasn't sure whether she believed in God. Since God and religion are merely a construct for moral/ethical decision-making, we were unconcerned about whether she believed in "God" but were very concerned that she develops a solid framework for distinguishing right from wrong.

Cohen's ethics column was a non-threatening, familiar vehicle for helping Athena navigate through the process of maturing her moral framework. After 10 months, Athena developed her own set of "ethical decision guidelines" that she proudly shared in her Bat Mitzvah speech with our 130 guests: When faced with a dilemma, avoid decisions/actions that:

are against the law
don't give you a good gut feeling
you wouldn't be proud to tell your mom
you wouldn't want on the front page of the Wall Street Journal

Making ethical decisions is learned, not innate. It’s a skill, not a talent. It takes practice and improves with feedback, debate, and, most importantly, self-reflection. It requires that you look at your own actions and honestly assess your intentions.

Is it ethical to sign an employment non-compete without really intending to honor it since its unlikely to be enforceable anyway?

Is it ethical to use ICD-9 codes that are not accurate but that assure a patient's medical services will be reimbursed?

Is it ethical to accept a Senior Discount when a hotel clerk mistakenly assumes you are over 65?

Is it ethical to have dinner with a friend when on a business trip and then submit the entire restaurant bill as a business expense?

What decisions would you make in these scenarios? Some may seem so innocent…but are they?

Cohen may be retiring his column but his dilemmas are very alive on the New York Times website. Read them. Debate them. Help your kids mature their moral maturity and continue to refine your own. We all need probably need some help in this arena. It’s a process that never ends.

Create Health,
Archelle

5 Ways To Boost Patient Self-Management of Care

2011-02-23T16:14:00.000-06:00

Most clinicians agree that if patients took more personal responsibility for their health, we'd have a healthier society and lower costs. But, what is the responsibility of clinicians to promote self-care? And, do we promote and encourage it...or do we subliminally create barriers and obstacles for patients? Do we really want them to be empowered...or not?

What will it take to help people help themselves when it comes to their health? This will be the theme of an upcoming keynote presentation I am doing at the Dorland Health's Care Coordination Summit in Las Vegas on March 8, 2011. As usual, I will be pushing the envelope and challenging the audience to re-define the definition of "care"--what it is, where it is delivered, and who delivers it.

As a preview to the event, the following article was published by Dorland Health....

5 Ways To Boost Patient Self-Management of Care
By Richard Scott
February 15, 2011

With the emergence of patient-centered care comes the express need for patients to move into an active role and take ownership of their care – an increasingly crucial characteristic to success. Yet propelling patients into this position of empowerment can be a tall task. What are the best ways to effect positive self-change in individuals?

We posed the question to healthcare consultant Dr. Archelle Georgiou, founder of Georgiou Consulting who will deliver a presentation titled Help People Help Themselves at the Care Coordination Summit on March 8 in Las Vegas. Dr. Georgiou offered the following tips to thrust patients into greater control of their health and healthcare.

Look past the condition. If this list of advice can be summarily divided into two parts – one oriented to how the healthcare practitioner approaches the patient and the other focused on a patient’s own recognition of care ownership – this first point falls into the former category. “The starting point is for the clinician to recognize that you’re dealing with the wholeness of the person and not just the condition,” says Georgiou.

While clinical skill is ever-important, the initial – and continuing – approach to how a physician or other member of the treatment team views a patient perhaps has more to do with good outcomes than clinical skill alone by engaging the patient in their own care from the outset. Only positive things will come out of that approach.

Look past clinical skill alone. Expanding on the above area, it is important to further engagement with the patient’s complete mind-body dynamic. This means more than relying on top-rated medication or surgical interventions or other evidence-based approaches. It’s key to focus on “marrying that with some things we forget to incorporate into a treatment plan, like mind-body medicine, relaxation techniques, stress [management] techniques,” says Georgiou. “It’s one thing to give a pill for anxiety. And it’s another to engage someone and empower them to do meditation-based stress reduction.”

Bolster communication. A two-part strategy, effective communication involves open discourse between both the treating team members and the team and the patient. “We have a culture that in some ways has encouraged patients to be passive about their own health,” says Georgiou. “Part of it is the communication that clinicians expect and give permission to patients to take charge of their own health.”

Expand your knowledge base. As patients feel more comfortable taking charge of their health, it is incumbent on them to become aware of their general health status and their treatment plan. In owning their treatment, patients can create personal health records or be knowledgeable about their office-based electronic medical records (if they exist). Of course, in many cases a clinician’s overall approach to how they deliver care (see the first two points) will go a long way toward deciding how engaged a patient will be.

Open up new lines of knowledge acquisition. The immediacy of information-sharing today means that there are many avenues patients can use to acquire information about their illness or treatment plan. According to Georgiou, social networks – online medical sites and discussion forums, for instance – are a vastly underused resource. “There’s a whole other sphere to where people can receive care, advice and support that clinicians typically don’t tap into,” she says.

With the care landscape changing, the most advanced clinicians and their teams will need to adapt to new ways of delivering medicine – not simply to keep pace but to remain ahead of the game.

Yes, Size Matters

2011-02-14T11:01:00.000-06:00

The President quit smoking. Yup, it's true. The First Lady said so during a press conference last Tuesday. Later in the day, Robert Gibbs, the Press Secretary, confirmed that the President has worked hard to kick the habit.

Well, only the Secret Service knows for sure whether or not the President is still sneaking a few puffs. But, regardless, I admire his accountability to himself, his family and to the public. Obama has 'fessed up to his vice. “This is not something that he’s proud of – he knows that it’s not good for him,” Gibbs told reporters. Obama hasn't tried to rationalize his behavior or made excuses. And, he hasn't implied that simply cutting back is good enough. He has plainly said that smoking isn't good for him...or for anyone else.

Compare that to Surgeon General Dr. Regina Benjamin. Lets call it like it is...she's fat. And, so are 63% of Americans. But, the real question is: Is she accountable to herself and, more importantly, to the public? Is she helping address the obesity epidemic...or is she fueling it?

Having a svelte figure is not, and should not, be a prerequisite to being "America's doctor." Many who have defended the Surgeon General argue that her job is to make health care and policy decisions for the country -- "not to look hot in a pair of skinny jeans." Good point, great sound bite, but clearly a defensive stance. No one expects her to be thin--just realistic and evidence-based about her current weight.

Experts estimate that Benjamin is at least 40 pounds overweight and wears a size 18. Women in this size range report a BMI between 32-34, and using standard American size charts, her waist measurement is estimated at 34.5 inches. She is not a little overweight or in a gray zone. Benjamin squarely falls into the obese category and likely has an abdominal girth that is dangerously close to, if not over, a critical threshold. (FYI...a waist size greater than 35 inches in women and 40 inches for men is considered high risk.)

There is no question that she needs to lose weight. However, when asked about her weight issues in interviews, she rationalizes by focusing on her treadmill endurance and her goal of climbing Mount Kilimanjaro. "The goal isn't to lose weight," Benjamin frequently says. "It's to be healthy and enjoy it."


Same skeleton...with and without excess fat.

Take a look at this picture of a body with and without excessive fat. It's painful just looking at it. And, Benjamin doesn't have a weight loss goal? Really? Not even 5-10% of her body weight? What kind of a message is this? What if Obama said that the goal was not to stop smoking but to be healthy? The subliminal message: Its okay to be ~~overweight,~~ oops, obese.

Just to be clear: We shouldn't judge her on whether or not she actually loses weight. The reality is that Benjamin is unlikely to ever achieve a normal BMI just like Obama is likely to "fall off the wagon" within 6-12 months, But, she should walk the talk and face the facts. No excuses. No rationalizing.

Too personal? Not anyone's business? Am I being too harsh? Clearly an opinion some of you may have right now. Okay...regardless of whether she conquers her own weight problem or talks about, she should at least be straightforward with the the public about the health risks associated with obesity.

During Benjamin's confirmation hearings, she said, "being healthy and being fit is not about a dress size. It's about how fit you are at that moment in time." And, in a January 7, 2011 interview in the NYT Magazine, Benjamin said, "My thought is that people should be healthy and be fit at whatever size they are."

Translation for the American public: "It okay to be fat. The Surgeon General said so."

Benjamin's position is supported by data that shows that cardiorespiratory fitness (defined as exercise capacity) is a strong and independent predictor of cardiovascular disease mortality and may mitigate the increased risk of death associated with obesity. In other words, she is promoting the perspective that overweight people who are "fit" may be healthier than those who are thin but sedentary.

Don't get too excited and start eating more Twinkies. This unbalanced view ignores other well-documented studies showing that weight, and particularly abdominal girth, is an independent risk factor for cardiovascular disease. In addition, do I need to remind you that excess weight is associated with a multitude of other conditions including sleep apnea, infertility, arthritis, depression anxiety, and certain cancers? Less commonly known is that obesity can lead to non-alcoholic fatty liver disease--an asymptomatic condition, that can lead to liver fibrosis or cirrhosis. In children, obesity contributes to poor academic performance, bullying and low self-esteem. The list goes on and on.

So, while getting fit is associated with reducing some health risks, failing to tackle the fat problem is linked to many more.

No, you can't be obese and healthy just like you can't be a smoker and be healthy. The Surgeon General has a responsibility to educate Americans based on evidence-based medicine rather than politically correct messages. And, while every public figure deserves their privacy, she should take a lesson from her boss and stop dodging the issue.

Dr. Benjamin, your "prescription" to Americans is delivering a dangerous message.
America..size matters.

Create Health,
Archelle

Have Your Cake and Live It Too

2011-01-11T16:06:00.002-06:00

Ever have a deconstructed cupcake? It was our favorite dessert in QSine, the specialty restaurant aboard our cruise on the Celebrity Eclipse. Plain cupcakes were served with chocolate, vanilla, and caramel icing along with four types of sprinkles. While we all had the same ingredients, we each created our own (almost) perfect concoction.

And, during a long and relaxing sea day, I started reading “The 5 People You Meet in Heaven,” Mitch Albom’s fictional story about Eddie, an amusement park maintenance man who dies and goes to heaven. When Eddie arrives in the afterlife, he encounters five strangers, but then he realizes how each one of them had significantly influenced his life on earth as they taught him about sacrifice, forgiveness, love, and interconnectedness.

Who knows what happens when we transcend from this existence to the next. But, why wait for heaven? There are individuals who have stepped into your life and forever shaped who you are and how you think. They are the heavenly people you have met on earth.

Rich

Prom (1979)

At 16, I left home for the first time to attend an 8-week summer camp. During the day, I was part of a small group of students selected to work in a biological warfare laboratory in Fort Detrick, Maryland. At night, we integrated with a larger group of kids enjoying traditional summer camp activities. Too shy to participate, I sat by myself writing letters to my parents. Tired of coaxing me to get involved, all the counselors decided to leave me alone---- except Rich who thought I needed some individual attention. During his time off, he took me swimming and running and taught me to dance—all firsts for me and the first time I realized that love exists. While Rich and I may have had a different future had our lives intersected at another time, he is still my dear friend 33 years later.

Stephen

Dr. Kopits with his Little People

My first surgery rotation in med school was with Dr. Stephen Kopits, a pediatric orthopedic surgeon specializing in the treatment of dwarfs. Voted “Baltimore’s Best Doctor” I was most excited about scrubbing in with him during his famous 12-hour surgeries where he untwisted, de-coiled and re-built the skeletons of his very small patients. But, it wasn’t his technical excellence in the operating room that made an indelible mark on my career. It was the relationship he had with his patients.

Most of his “little people,” as they prefer to be called, ranged in height from 24 to 36 inches. At 6’2”, Kopits towered over them, even while sitting in a chair. So, in clinic, he’d sit on the floor, legs crossed Indian style, and made direct eye contact with his patients as he spent hours answering questions, drying their tears, and reassuring them that they could live a full and productive life. “Archondoula, always remember” he said in his thick Hungarian accent, “you have to love your patients.” I never saw Dr. Kopits after my rotation but when I learned that he died of a brain tumor in 2002, I sobbed. He taught me what it really means to be physician.

Jeannine

Jeannine holding one of her many awards

For the last 14 years, Jeannine has been a boss, a colleague, a friend, and a boss again—and, through it all….a coach. As a senior executive in UnitedHealth Group, she’s was in the position to lobby for opportunities on my behalf and helped advance my career. But, more importantly, she continually gave me constructive feedback. She expected data when I took a strong stand on issues and she demanded facts when I whined. She has made me aware of passive-aggressive body-language, counselled me on event-appropriate clothing, and helped me soften some edges –all with love and objectivity and without fear of consequence. Jeannine taught me how to demand accountability from myself and to inspire it in others.

David

David, is the man I married and continue to love dearly. Among his many qualities, the true gift he’s given me is his encouragement to take calculated risks and pursue my dreams. He hasn’t painted me into a traditional role as a wife, a mother, or a doctor. Even when he has pushed too hard…it’s been because he believes that I have the potential to reach a bit farther. David believed in me before I believed in myself.

There are others. Without them, I may have never recognized that I didn’t have to be “one of the boys” to be a successful woman in corporate America. I may have never figured out how to have happy, well-adjusted kids while being a working mother. And, I may have never learned that true friendship requires brutal honesty.

Love, compassion, self-confidence, accountability, sexuality, balance, friendship.

This is my story. But, how did you get there? The themes are universal---but the details matter and are uniquely yours.

Take the time to plot your own emotional growth on a graph. Who are the people responsible for the inflection points? What were the defining moments? We all learn and grow at different times, from different people, under different circumstances.

Just like the cupcake, reconstructing your life--piece by piece--helps you appreciate the whole. And, one last thing...it’s also an opportunity to identify what might be missing. In the future, I think I’ll order cream cheese frosting….along with a heaping tablespoon of patience.

Create Health,

Archelle

Heel (Heal) Like A Dog

2010-12-27T13:51:00.002-06:00

Have you ever wondered what dictates the pace of the healing process?

Why do some of people recover from a cold in a day and in others, it lingers for 1-2 weeks?

Why do some college students with mononucleosis lose a semester of college due to extreme fatigue but others just need a little extra sleep for a few weeks?

Why do some adults just take one day off from work to get their wisdom teeth extracted and others are home, on narcotics, for a week?

Yes, level of severity, comorbidities, and complications drive variation, but is the "each person is different" rationale completely about the differences in cellular physiology?

Exactly 2 weeks ago, Isabella, our 13 pound dog, a shitzu-bijon mix and a bit of a diva, was spayed. In human medical terms, she had a total abdominal hysterectomy--1-1/2 inch incision, anesthesia, and removal of her ovaries and uterus. When I picked her up from the vet, she was subdued, and as he handed her over, his post-op instructions were "Follow her lead, she'll tell you how she's feeling." Within 24 hours, she was eating and drinking with normal bowel and bladder function. She didn't appear to need any pain medication; in fact, our bigger challenge was trying to protect her stitches and keeping her from running laps around our kitchen counter.

As I watched her recovery, I was amazed. If she were human, she'd be in the hospital for 2 days, on narcotics for 2 weeks, and unable to drive for 4 weeks. And, regardless of the actual healing process, the "standard of care" would be for her ob-gyn to authorize 6 weeks of disability...whether she needed it...or not.

"Why the stark difference?"

There are many possible reasons. Clearly, dogs have a different biology than women. Their abdominal wall muscles are thinner and they don't experience the same hormonal shifts post-operatively. In addition, they are generally more physically fit which accelerates the healing process as well. And, age is undoubtedly a factor. Dogs are spayed when they are young whereas women generally have this surgery after age forty.

Nevertheless, Isabella's recovery was 20 times faster than the average woman's recovery. And, even if I take into account that 1 dog year = 7 people years....the recovery was still 3 times faster. Why? Are there other considerations?

The following offer some thought-provoking rhetorical questions.

Do women need the emotional healing time to deal with the loss of their reproductive ability and a fear of a loss of sexuality?

Do they need to protect themselves from the demands of work and home? One of the most popular articles on HysterSisters, a social networking/support site for women pre- and post-op, focuses on what NOT to do after a hysterectomy. The bullet point list reads like a strategic military plan for protecting oneself from colleagues and family.

Do people have a hard time asking for, and affording, a mental health break? How often do the final few weeks of prescribed disability offer a valid reason to be off work, receive a paycheck, and de-stress?

You may be wondering...why does this matter? Why dissect how much of the needed healing time is influenced by biology and how much by our brain? Because the care process is different.

Unfortunately, we have a medical system and a culture that understands wound healing but doesn't know how to support emotional healing. As a result, many women simply stay in a traditional "sick role" for longer than necessary...with the hope of getting their needs met.

The advice women give to each other in HysterSisters is "Don't act too good too soon. Even if you feel good, try to look lousy and weak. When you act better you automatically lose everyone's help and sympathy. Make it last because even though you feel better you still need the help..."

While adequate rest, activity limitations, antibiotics and pain medication support wound healing, they do not address how to cope with mourning, addressing fears, and managing stress. Dogs seem to escape these issues, but women don't. With 600,000 hysterectomies performed each year, think about how many womens' quality of life and productivity would be improved if they could stop being "sick" and get support they need for the emotional aspects of the healing process.

Create Health,
Archelle

PS: About 1 hour after I posted this blog, I got some constructive feedback that I could have been more "to the point." So, here is what I was trying to say:

There are various dimensions to the healing process: physical and emotional. But, the "system" and our culture only acknowledges one: being physically sick. So, what do we do? We stay "sick" for longer in hopes of being able to figure out the other one. But...is that effective? Or does it prolong the recovery process because meds, etc etc do not address the real needs?

Health News: Tips for Avoiding Sound-Bite Seduction

2010-11-30T11:46:00.000-06:00

"Morning Glory" starring Rachel McAdams, Diane Keaton, and Harrison Ford is a wonderfully funny movie about the behind the scenes challenges in broadcast news. McAdams plays Becky Fuller, an executive producer charged with revitalizing a failing morning news program. The painfully accurate reality depicted in the movie is that news outlets live and die by their ratings so that we, the viewers, can get the news for free.

So who pays for it? Broadcast, print and web news media is supported by advertising revenue, and the basic business model is straightforward:

News attracts viewers.
Number of viewers is monetized.
News outlet sells advertising space/time to marketers.
The more viewers there are, the more a media outlet can charge for an ad.

The bottom line is that Viewers = Revenue.

Retaining viewers/readers ultimately requires that media outlets deliver information that is timely, accurate, well-balanced, and engaging. However, attracting them requires that outlets successfully break through the morass of news noise. How do they do that? By grabbing our attention with clever, dramatic headlines and teasing viewers/readers with lead-ins and headlines that are unexpected, outlandish, and extreme. It is a bait and hook strategy that works.

Here’s the problem: Too often, we don’t have the time to read or listen to an entire news clip or article. We merely rely on the headline and, subsequently, we become misinformed. And, when there is misinformation about health-related issues, this can lead to poor outcomes, higher cost, and, very commonly, patient confusion, frustration and disappointment.

Here a few examples:

Headline: "Study Pins Alcohol as More Dangerous Than Crack or Heroin"

Facts: This Lancet-published study evaluated 20 different drugs including cocaine, heroin, ecstasy and marijuana. Each was ranked on three dimensions: physical harm to the individual user, addiction potential, and the societal effect of the substance. The study clearly showed that an individual level, cocaine and heroine are most harmful. But, since alcohol abuse is so prevalent in the population, its high societal impact score inflated the overall score above that of all the other substances. Hence, the headline.

By the way, the author of the article is Professor David Nutt, a former U.K. drug czar who is using the study to argue that the regulatory classification of substances should use an evidence-based rather than a historical approach rather. This was a political article in drag.

The vast majority of online outlets including ABC, CBS, and FOX, had a headline similar to the one in Time, but kudos to The Boston Herald for their responsible but still eye-catching headline: "Dangers of Abuse Sobering."

Headline: "Botox a Cure for Migraines?"

For the 3.2 million people who suffer with migraine headaches, this headline created a groundswell of hope.

Facts: In this study, Botox for migraines was only tested in patients with 15 or more days of headaches per month. There was no difference in the number of headaches, but treated patients had 1.4 fewer headache days per month. For effectiveness, each quarterly treatment session requires 31 injections of Botox, and the annual cost is about $4000 per year. Individuals with chronic migraines may get some relief with Botox but it is certainly not a silver bullet or a “cure for migraines.” While Botox can be used off-label for those with less frequent migraines, it has not been studied and it is unlikely to be covered by insurance.

Oh, by the way….the new migraine indication for Botox is estimated to add $1 billion to Allergan's top line within five years.

Headline: "New 'Vaccine' for Prostate Cancer"

When I mentioned this headline to David (my gastroenterologist husband) he said, "I want it," until he heard the facts.

Facts: The Provenge "vaccine" is not preventive at all. This medication is only for men with late stage, metastatic, hormone-refractory prostate cancer. Even for them, its not a cure. The drug extended survival an average of 4.5 months (from 22 to 26 months) and costs $93,000.

So, why is Provenge called a vaccine? It’s a technicality. Each "vaccine" is custom-manufactured using the patients own cells. The infusion does not directly attack the cancer; rather, it triggers an immune response against the tumor cells just like the flu "vaccine" triggers an immune response against the virus. Clever, huh?

And, finally, one of the biggest media/government headline blunders of the decade.

Headline: "Government No Longer Recommends Routine Breast Cancer Screening for Women Under Age 50"

Fact: The headline is only half right. The original recommendations issued by the US Preventive Services Task Force were published with the following language:

"Women 40-49: Do not screen routinely. Individualize decision to begin biennial screening according to the patient's context and values."

I have already pontificated about this public relations mess in a November 2009 blog that you can read here.

What You Can Do

The news media’s financial incentives make it unlikely that attention-grabbing headlines will go away. So, here are a few suggestions to avoid being seduced by the sound-bites:

1) If you only have time to read or listen to a headline, treat the information as if it’s gossip. Fun to read…but let it go in one ear and out the other.

2) Does it sound too good to be true? It probably is. Nevertheless, if you’re intrigued by the story, make the time to read/watch the entire piece.

3) Is the headline interesting enough that you’d mention it to a friend or your significant other? Maintain your credibility. Go to Google Health News, find the story and click on “All News Articles.” Then, select an article published by a national online newspaper such as the LA Times, NY Times, or USA Today. Business Week and Associated Press articles are also consistently reliable. Avoid reading the web articles published by broadcast media (ABC, CBS, Fox, etc), local newspapers, or blogs.

4) If you think the headline may be relevant to your health, do #1-3 above. Then go STRAIGHT to the source. Most of the web-based news media articles link to the published journal article or government site (FDA, NIH, CDC) from which all media articles are based. Read it. You are smart, and you are just as able to interpret it as the journalism or marketing/communications major who wrote the first piece you read. Even if you can only tolerate reading the abstract, you will get an objective angle on the study findings. Finally, if you feel you need help interpreting the scientific data, go to WebMD’s News Home page. The articles in the center of the page are non-sponsored and subject to WebMD's editorial review process.

The Internet has democratized the availability of information. New medical research, technologies, and insights are no longer sequestered in the tombs of professional journals, and doctors are no longer the gateway or gatekeeper of emerging clinical knowledge. But, remember, in every control room is an executive producer saying the same thing as Becky Fuller, "Every single story that we do is gonna have to be sensational!"

Create Health,
Archelle

Get Uncomfortable...Get Successful

2010-11-09T09:00:00.001-06:00

“Maria’s Event” is how the insiders now refer to California’s annual Women’s Conference. They are referring to Maria Shriver who assumed responsibility for the event seven years ago when she became California’s First Lady. Oprah summarized it well when she said that Maria has transformed the event from a small, poorly attended meeting to the “hottest, hippest, highest attended women’s conference in the world.”

The overarching goal of the Conference event to inspire women to be “architects of change,” but Maria has also used the conference as a vehicle to work through some of her own challenges—from her reluctance to being a ribbon-cutting First Lady to enduring the sadness of her mother’s death. While she stacks the stage with a star-studded platform, the real magic of the Conference has been Maria’s willingness to be honest and transparent in front of thousands of people. And, making herself vulnerable makes her real….and gives others the courage to do the same.

Shriver’s theme for the 2010 Women’s Conference was “It’s Time” which reflected that “its time” for her to transition this conference to California’s next governor. For each woman in the audience, the theme meant “it’s time” to make the personal and/or professional changes that moves each person toward a happier, more meaningful, life. And yes, Maria said, change is scary.

Two weeks ago, I attended the Conference in Long Beach as part of EmpowHER, a health media company focused on helping women advocate for themselves. We were there to film a series of Web-TV shows from the exhibition hall floor on a variety of women’s health topics. Beyond conducting eight engaging interviews, my only other goal was to try to “bump into” a celebrity or two. (Matt Lauer would have been nice.) But, as the two-day event unfolded, ata persona level, I realized that “It’s Time.”

Day 1 was a “Night in the Village.” The Long Beach Convention Center was overflowing with 14,000 people, hundreds of vendors, free samples, lots of bling, and a dizzying amount of noise. With each “Maria sighting,” crowds rushed through the aisles to catch a glimpse. Feeling overwhelmed, the introvert in me wanted to retreat to my hotel room, crawl into my PJs, and watch the events via webcast. Had I done that, I would have felt a little safer, but I also would have missed the opportunity to experience the energy that is generated when women become a community and share their stories.

Fortunately, I reverted to my extroverted side. I took a break from our makeshift studio and wandered from booth to booth. I was most inspired by the innovative products sold by small, women-owned businesses. Some were simple but practical—like the clothes hangar labels designed to remind you of the date and location that you wore a certain outfit. Others were deeply moving—such as the intricately, hand-embroidered luggage from Afghanistan that uses micro-financing to promote women’s rights. Some were just incredibly creative—

like Topsies…a flip-flop alternative that uses fun patterned stretch fabrics to create shoes that have all “flip and no flop.” Regardless of the size or scope of the business, each one was started by a woman who had a spark of creativity, believed in herself, and had the courage to take a risk. It made me question whether I had approached the last 3 years, a new career chapter of my life, with the same zest and confidence as these women.

Day 2 was called “A Day of Health, Wellness and Transformation.” Our day centered around doing six segments—all scripted, all highly staged. But inspired by the Village, I took a risk. I asked the producer to shut off the teleprompter, and I tossed aside the formal, science-based questions I had prepared for our experts.

Instead, I asked the real questions that were on my mind. During an interview with Dr. Hilda Hutcherson, sexual health expert and OB-Gyn professor at Columbia University, I asked her how, exactly, to maintain an active sex life, even when sexual desire is waning. Was this too personal, too transparent? Not professional enough? “This is Intense, “ she said,

as she opened a bag full of K-Y Jelly’s newest sexual enhancement products and proceeded to describe how they work.

I asked questions that I didn’t already know the answer to. When I interviewed Dr. Phillip Sarrel, head of the Yale Menopause Program and an expert in estrogen’s effects on arterial blood flow, it was enlightening to learn that there is interdependence between an active sexual life and a healthy cardiovascular system.

I let myself experiment. Dr. Mao, a nationally known Chinese Medicine doctor, was describing how acupuncture can be used for facial rejuvenation so, I volunteered to let him do a live “facelift” demonstration on me with the camera rolling and dozens of women watching. Yes, that’s a picture of me with 10 needles in my face for 20 minutes. No, it didn’t hurt. Does it work? Topic for another blog.

And, I let myself have some fun. During a break before our final segment, I stumbled into “Godiva’s Secrets.” No, not the chocolatier—a wig vendor. After 20 minutes of staring at other women trying on wigs, I mustered up the courage to try one. The shaggy, longer style with the wispy bangs immediately made me feel a little sassier and a little sexier. Five minutes and $179 dollars later, I owned the wig and taped our final segment with a new hairstyle. For those who know me well, you know that it is completely out of character for me to be this spontaneous.

Maria’s event inspired and energized me to stay focused on my passion to “Create Health.” But, it’s time. It’s time for me to trust that my experience and clinical curiosity will guide me through an interview. It's time to have the self-confidence I need to let myself be vulnerable. It’s time to be me. And, doing that publicly is scary. But, as Maria said, “It’s only when you allow yourself to explore the unknown that you discover your strengths.”

Create Health,

Archelle

From The Triple Crown to Trivalent Vaccine--How Did I Get There?

2010-10-19T10:31:00.002-05:00

Aren't movies a great value? In addition to offering two hours of entertainment, they often inspire us to wander into tangential questions and dilemmas that might otherwise remain unexplored and undiscussed.

Disney's Secretariat is a wonderful family movie about a racehorse who, in 1973, became the first Triple Crown champion in twenty-five years when he won the Belmont Stakes by 31 lengths. The movie is also about the his owner, Penny Tweedy.

Penny (Chenery) Tweedy is a Columbia Business School graduate turned housewife. She is married to a successful attorney and is the mother of four children. But, when she assumes responsibility for her father's ranch, she shifts her focus away from her family and on to the horse and on to winning...at all costs. As usual, Disney glamorizes her passion and glosses over the family conflicts, but in a recent article by her Penny's son, John Tweedy, he said, "In real life, we Tweedys were more riven and frayed...by the pressures of celebrity into which we were suddenly thrust. The wars between our parents were more bitter, the marriage more broken, and we kids were more alienated and countercultural than the movie depicts."

During the scene when Penny turns down $8 million dollars for Secretariat and risks the family estate, David, my husband, turned to me and said, "Archelle, even though I know how this movie ends, she is really being irrational." Or, was she?

And, at that moment, my tangential thinking began....

When should a "housewife" give up her dreams and what she believes in for the good of her family?

Why should 6 men voluntarily descend 2041 feet into the San Diego Mine escape shaft to help save 33 others who were buried alive for 67 days.

These are questions of utilitarianism, a moral theory centered around the basic concept that "actions are right to the degree that they tend to promote the greatest good for the greatest number." While I don't fully understand all the nuances, the basic concept is one that's been on my radar for a few weeks since Athena called me to brainstorm about an essay for her freshman Ethics class. "Mom, when do the needs of the community supercede the needs of the individual?"

Her question brings me to this blog topic:

When should a health care provider get the influenza vaccine (even when they don't want it) to prevent putting vulnerable patients at risk?

There is strong data suggesting that health care worker vaccination is effective in controlling institutional outbreaks and decreasing flu-related morbidity and mortality. And, there is agreement that the risk of serious adverse effects from immunization is very uncommon. Nevertheless, voluntary vaccination programs have been unsuccessful, and according to the National Health Interview Survey, only 49% of workers were vaccinated during the 2007–08 season. The reasons cited for not getting immunized were not philosophical or based on medical contraindication. Rather, individuals expressed doubts about the actual risk of influenza, concern about vaccine effectiveness and side effects, and dislike of injections.

Clearly utilitarian principles are not dominating the decision-making framework for the 51% of health care workers declining vaccination, and therefore, a bigger question arises: Does the government have an obligation to act? Should flu vaccination be mandated through legislation...for the greater good?

Proponents of a legislative mandate argue that vaccination is a moral obligation given the trust placed in their hands by both patients and the institutions for which they work. Furthermore, they claim that not getting immunized violates the rights of those who expect to be cared for in a safe environment. Legally, there is Constitutional precedent for mandatory immunization. In the 1905 smallpox-vaccination case, Jacobson v. Commonwealth of Massachusetts, the U.S. Supreme Court recognized that the “police powers” granted to states under the Tenth Amendment gives the government the authority to impose restrictions on private rights for the sake of public welfare.

Opponents, however, argue that mandatory vaccination violates individual rights, including the right of competent adults to make decisions regarding their medical care. In 2009, when the Health Department in New York ordered all health care workers to get vaccinated for H1N1 and seasonal flu, the order was withdrawn after strong opposition by the New York State Nurses Association and multiple unions.

In 2010, however, the issue is back on the table---not only in New York, but across the nation.

Proponents point to organizations such as Virginia Mason Medical Center in Seattle, Washington, and BJC Healthcare in St. Louis, Missouri, that have achieved immunization rates surpassing 98% by mandating vaccination as a condition of employment. Opponents say that these examples are employer-mandates, not legislative mandates. The fear is that governmental interference will set the stage for broader government control of personal health care issues. And, in sticking with the utilitarian theme, opponents could argue that freedom and choice are the most important outcomes for a democratic society.

So, what do I think?

Voluntary immunization: Of course.
Employer-mandates: Yes, with a well-defined process for medical and religious exemptions.
Legislative mandates: I abstain.

Unfortunately, we are 1/3 of the way through this flu season and will doubtfully make much progress as the nursing unions, politicians, hospital executives and infectious epidemiologists continue to battle this out. Another solution?

How about requiring health care workers to wear a button that clearly states if they got the flu shot--or not. And, give patients a choice about whether to be cared for by someone who is not immunized. Health care workers who choose to put individual preferences ahead of the care and safety of their patients will have some (uncomfortable) explaining to do. I suspect that the majority who are forced to face this moral dilemma at the bedside will reconsider their decision..simply because its the right thing to do.

Empowering consumers may help win the race in preventing some of this years 36,000 influenza-related deaths.

Create Health,
Archelle

Sexx Matters*

2010-10-05T12:50:00.001-05:00

10th grade Social Studies class. My first term paper. Typed on a Remington Select with bottles of White Out and typewriter correction tape by my side. The topic: The Equal Rights Amendment (ERA).

In case you haven't read it lately, the language in the ERA simply states:
Section 1: Equality of rights under the law shall not be denied or abridged by the United States or by any state on account of sex.
Section 2. The Congress shall have the power to enforce, by appropriate legislation, the provisions of this article.
Section 3. This amendment shall take effect two years after the date of ratification.

The Amendment was originally introduced in 1923. In 1972, it finally passed in both the House and Senate but sits dormant, and is not part of the US Constitution since it has only been ratified in 35 of the necessary 38 states.

As you might expect, I took the position 30+ years ago that the Amendment should be passed. And, I still do. Not because women still need equal due process rights; the 14th Amendment takes care of that. Not because women still need equal opportunity for employment and compensation; the Civil Rights Act of 1964 and the Equal Pay Act (1963), theoretically at least, afford these protections.

The ERA needs to be passed so that women finally have an equal opportunity to achieve and maintain their health.

Two weeks ago, the Institute of Medicine published a report: Women's Health Research: Progress, Pitfalls, and Promise. This report was commissioned by Health and Human Services to examine the status of women's health research over the last 20 years and to determine how effectively findings have been put into practice. The report's findings highlight that, indeed, there has been progress, particularly in the treatment of women with heart disease, breast and cervical cancer. There is a longer list of conditions for which progress has not been made.

Among the findings that I want to call attention to because, frankly, they are appalling, are those regarding the inclusion of women in clinical trials. Here is a brief synopsis...Comments in parentheses are my editorial comments. What are blogs for, anyway?

--Pre-1986: Women were not routinely included in clinical trials. There was an assumption that results of research on men could be extrapolated to women.
--1986: The NIH established a policy requiring the inclusion of women in clinical research.
--1990: A GAO audit identified that women were still not adequately represented in clinical trials. Why? The policy was vague, inconsistently applied and poorly communicated.
--1992: Another GAO audit found that while women were included in trials, they were underrepresented. (Oops..must have been another misinterpretation.)
--1993: The FDA issued new guidelines for requiring inclusion of women in clinical trials and required gender specific analysis of the data.
--2000: A GAO audit revealed that although women were included and adequately represented, studies were not adequately designed to permit analysis by sex.
--2001: A GAO audit of the FDA showed that 30% of studies failed to fulfill requirements for outcome data by sex. Clinical significance? Eight of 10 drugs withdrawn from the market caused more adverse effects in women.
--2001: The Institute of Medicine published Exploring the Biological Contribution to Human Health: Does Sex Matter?

Yes, Virginia...sex matters. But, it is 2010 and women are still under-represented and comprise only 39% of the participants in Phase 1 trials...the phase that assesses the safety, tolerability, and dosing of a drug.

Not outraged yet? What if you knew that:

--During the height of the H1N1 vaccine shortage, researchers identified that women could be immunized with a lower dose of the vaccine and get adequate protection since we have a more pronounced immune response. Great news, right? Regulators were informed, but said they were too busy to consider this information in the vaccination guidelines
--Prominent researchers were recently discouraged from submitting any new grant proposals to the NIH for research on sex differences of mental health disorders. Does this make sense since science can’t yet explain why depression is twice as common in women, alcoholism is twice as common in men, eating disorders are three times more common is girls and autism is four times more common in boys? Nope. What are they thinking?
--Male mice, rats, and rodents are even preferentially used over females in basic clinical research!

What will it take to make women's health a priority in clinical research? We have Federal laws, NIH policies, FDA guidelines, four separate Federal agencies with an "Office of Women's Health," and repeated GAO audits...but the status of women's health research is abysmal for a nation that spends almost $3 trillion on health care. We've come a long way baby...but not far enough, and we may need a 28th amendment to the Constitution to finally have equal rights to a healthy life.

What can you do? Whether you are male of female...
Read the report. Educate yourself on sex-based differences. Advocate for yourself..men are from mars, women are from venus, and sex matters, damn it!

Create Health,
Archelle

*"Sexx Matters" is the creative brainchild of the Society for Women's Health Research...an organization that works tirelessly to promote and advocate for sex-based differences research.

How A Gorilla Improved My Memory

2010-09-14T23:13:00.002-05:00

Mosque versus no mosque near Ground Zero. The Health Reform bill is good; it's terrible. Jeff Skilling is a criminal; Skilling was a scapegoat. Marijuana should be legalized; it should remain illegal.

How often have you shifted your position on any of these issues? The likely answer: not often. We watch news programs that are generally aligned with our political orientation. We seek conversations with others who share our position on a controversial topic. We surround ourselves with a world that agrees with us. As a result, we rarely change, or even reconsider, our point of view.

Many of you have seen the famous Invisible Gorilla experiment. If you haven't, take a look at it here. For those of you who have seen the original video, take a look at the follow up experiment.

This phenomenon is called “selective attentiveness” --our natural tendency to pay attention only to messages that reinforce our own attitudes, opinions and beliefs. And, not only does it make us narrow-minded, it can negatively impact health.

Speaking of health…

"I am having a senior moment." I dread when I have to say this. It means that my mind has drawn a complete blank, and no matter how hard I try, I can't remember your name, what city I travelled to earlier in the week, or the name of the restaurant I was just raving about. The self-deprecating chuckle that accompanies my “excuse" is merely a quick cover-up for my fear: Am I getting Alzheimer’s? Probably not. Too young, no family history, and my genetic tests show I don't have an increased risk. I didn't score high on the online Alzheimer’s tests (whew!). But, what’s wrong?

I developed a few theories:
• I am stressed.
• I am not get high quality sleep. The early morning sunshine streaming into our bedroom could be disrupting my REM sleep and circadian rhythms.
• I am peri-menopausal. Maybe I need a little patch of testosterone. It reportedly improves memory, general well-being, and a few other things.

And, of course, the really irrational theory:

• We have a problem in our home. "David, do you think we have radon or carbon monoxide problems in our house?"

I started meditating and checked the air sensors. I tried wearing a blindfold to bed and did a few other wacky things. But, there was no improvement until we were in Greece. Two weeks into our vacation, I noticed that I wasn’t apologizing for forgetting names. My thinking was sharper, and the vague headaches I had tolerated for the last several years were virtually gone. Finally, I was able to stay awake past 8:30 pm.

However, soon after returning to the US, all the symptoms were back--in full force. While driving on 394 West, there was an episode when I simply couldn't remember where I was going.

I dissected the differences between the US and Greece and realized that the most likely culprit was:

aspartame—the artificial sweetener marketed as Equal and NutraSweet. In the US, my daily consumption of these little blue packets was averaging 30 packets a day. But, in Greece, my consumption immediately dropped to zero since saccharin, not aspartame, is the predominant sweetener. So, I eliminated all aspartame from my diet—no little blue packets, no diet drinks (unless they are made with Splenda), and limited amounts of sugar-free gum. The hazy thinking and senior moments virtually disappeared. While I am thrilled, and very relieved, I am also intrigued by the power of the human mind to play tricks on us.

According to the FDA, the acceptable daily intake of aspartame is up to 50 mg/kg. Per the government's standards, I could theoretically have up to 110 packs per day (22 mg/pack) and stay in the safe range. And, the FDA’s statements are what I relied on whenever someone said, “Archelle, you use so much of that junk. Its not good for you.” I’d simply scoff and roll my eyes. At 16 calories per teaspoon of sugar, I was saving myself 960 calories per day, and I had no interest in eliminating the use of artificial sweeteners from my diet. I liked the FDA’s position and that was that!

Moreover, this wasn’t a situation where I simply chose to accept the risks associated with aspartame in exchange for the caloric benefit. The would have just been poor judgment. In this case, I was completely unaware of the literature, the long standing controversy, and the risks. Despite being a health information junkie, my selective attentiveness only let me “see” the data I liked.

For four years, I didn’t see the gorilla, the broad body of scientific evidence suggesting that aspartame has harmful neurologic side effects with headache, confusion, memory loss, and fatigue cited as the most common. Aspartame is the subject of 75% of the food additive complaints to the FDA, and a review of 165 studies by Dr Ralph Walton, a professor of Clinical Psychiatry, showed a suspicious relationship between study results and their source of funding. Of the 165 studies, 74 had industry related funding and 91 were independently funded. Of those:
• 100 percent of the industry funded studies supported aspartame's safety, while
• 92 percent of the independently funded studies identified at least one potential health concern.

Don’t use any artificial sweeteners? Good. You are more likely to remember the main point of this blog. Selective attentiveness is a human trait, but we can take steps to overcome it. Find the gorillas in your mi(d)st. Commit to regularly watching a news station that makes you bristle. Visit the web site of the candidate you adamantly WILL NOT vote for. Stop talking at others when discussing a controversial topic and really listen to the opposing point of view. Give yourself the opportunity to live in a bigger world.

Create Health,
Archelle

Doctor Shortage: A Blessing In Disguise?

2010-08-24T15:39:00.000-05:00

As the details of healthcare reform unfold, there is speculation, and concern, about how the Bill will impact access to care. With forty-six million additional people having insurance, will there be enough doctors to meet the increased demand? According to the American Medical Association there will be a shortfall of between 124,000 and 159,000 physicians by 2025. While that seems like the distant future, there are at least 22 states that have already reported physician workforce shortages.

We need a proactive, comprehensive strategy to address this issue which should include expanding the number of residency positions, offering incentives for physicians to practice in underserved areas, and expanding the scope of care delivered by nurses and other clinical professionals. But, these strategies only address the supply side of the supply-demand equation.

How about (also) addressing the demand side? What if we encouraged people to seek preventive, urgent and emergent care but discouraged them from going to the doctor "willy-nilly" for symptoms that would have resolved on their own anyway? Not only would we increase capacity in the system, we might even get healthier, suffer fewer errors, and live longer.

I was interviewed about this idea by Big Think, a "global forum connecting people and ideas." Their site is not shy about being provocative, questioning the status quo and grabbing readers' attention with big, bold headlines.

Here is a link to the article, "Doctors Are Bad For Your Health."

Create Health,
Archelle

"I Do." Vows to Keep In An Interfaith Marriage

2010-08-19T11:30:00.000-05:00

The marriage of Chelsea Clinton and Marc Mezvinsky generated speculation about how this couple's religious differences would sort themselves out:
How will they raise their children?
Will she convert?
Will he keep Kosher?
And, of course: Will they have a Christmas tree?

The newly married couple has been spotted in Namibia on a safari. But soon enough, the honeymoon will be over. Since I have a bit of experience regarding interfaith marriage, I thought I’d offer some unsolicited advice.

Dear Chelsea and Mark,

David and I have been married for 22 years. While the religious details of our wedding are a bit different than yours--I converted and we had a Conservative Jewish wedding--we have faced many of the joys struggles of an interfaith marriage. So, I thought it might be helpful to share what we have learned as the two of you begin your new life together.

--Don't ever EXPECT that your spouse will change their values or their belief system. While an individual’s religious beliefs can evolve (as mine did), that change can only come from within. Even then, it’s really hard. I sailed through my conversion process that consisted of “10 Easy Lessons to Becoming Jewish.” Then I spent the next 10 years figuring out (and struggling, at times) how to embrace a new faith while honoring and respecting my past.

Mark, I was thrilled to see that you signed a Ketubah, stomped on a crystal glass, and danced the hora on your wedding day. Chelsea, I hope that you, too, incorporated equally meaningful symbolic moments into your day. To be honest, I was a little worried that they weren’t as evident in all the pictures that we saw. Remember, each of you has entered your marriage with over thirty years of traditions-—family traditions, religious traditions, cultural traditions. They make you who you are. Getting married is an opportunity to share them…not abandon them.

---Decide what religious beliefs and traditions will guide the upbringing of your children, and, figure it out well before they’re born. We got this one right from the beginning. In our case, it was easy; the kids would be raised Jewish. But, in 1994, during a moment of inconsistency, I talked David into letting me decorate the house with garland during the “winter” holiday. I rushed off with Arielle to Michael’s Crafts, and while we were in the checkout lane, she said "Mommy, why are you buying that? We don't celebrate Christmas." My 5 year old's reminder made it easy to leave the store empty-handed. Do your kids a favor---don't confuse them. Children look for unity in the messages that they get from both parents.

--Intrafaith differences are just as important to address as interfaith differences. David, the grandson of an Orthodox rabbi, grew up in a traditional Kosher home. Fasting on Yom Kippur really meant eating absolutely nothing! I, on the other hand, was raised in a home where fasting for Easter simply meant not eating meat on Good Friday. We entered our relationship with very different expectations of our levels of observance, and it took several holiday cycles to find some common ground. Here’s the best advice I have on this issue: compromise.

Its easy to think that I was the one who compromised most in the relationship. I though so too, for twenty years, until June 2008 when Fay, David's mother, passed away unexpectedly. I saw my husband fully immerse himself in the Jewish Orthodox funeral traditions--sitting shiva, remaining unshaven, wearing a torn shirt and tie for a week and committing to saying Kaddish for a year. I realized that at his core, David is highly observant because he finds comfort in the structure of organized religion. But, he had quietly and willingly given that up and, on the surface at least, he settled into the looser traditions of Reform Judaism so that we could live our life together.

--As your children mature and recognize that you came from different backgrounds, be prepared for questions that challenge and explore your deepest held assumptions beliefs. Our girls attended the funerals of 2 grandparents in one year. Fay's had a closed casket. My father's Greek Orthodox funeral had an open casket accompanied by wailing women in black veils. Why the difference? Which approach offers a greater sense of closure? What would the girls each prefer when they die? Can they be Jewish and still have an open casket? Arielle has made the decision, at the age of 20, to document a specific, customized interfaith approach to her own future funeral so that it can be exactly how she wants. These conversations aren't for the faint-hearted.

Chelsea and Mark, you are both highly intelligent people and clearly thrive on intellectual and spiritual stimulation. If you are open and accepting, your interfaith marriage can be an ongoing journey that is just as enlightening as it is challenging.

Mazel Tov,
"Συγχαρητήρια για τον γάμο σας"

Archelle (and David)

Long Live The Greeks...But Will They Prosper?

2010-08-11T20:00:00.001-05:00

Celebrity chef, Andrew Zimmern, said it well in a recent article, "Headlines be damned. Greece is still open for business."

Well, sort of. . .

My family and I recently returned from a month long trip to Greece. Indeed, it was glorious, and it would be fun to write about the exquisite meals, the inspiring history, and the experience of "moving in" to Lahania, the small village (population: 50) where my father was born. But, that's not what I'm writing about because, frankly, I expected that we would have a wonderful vacation. What I wasn't expecting is that I would get an insider's view of the Greek economic crisis.

It started the moment we arrived. The plan for our first full day in Athens was to visit the New Acropolis Museum that opened to rave reviews in 2009. It cost $200 million and sits near the base of the Acropolis with a direct view of the Parthenon. BUT....we were promptly informed that the museum was closed. In fact, all of the historical sites were closed due to a 1-day national strike. Two and half million public and private sector workers in Greece were on strike in Athens and other major cities protesting the European Union-International Monetary Fund austerity measures. This particular strike was scheduled on the same day that the Parliament was voting on a bill to increase the retirement age to 65 and decrease early pensions for workers. FYI...the Greek government has policies that promise early retirement (age 50 for women and 55 for men) to 700,000 people. Warning: Don't get in between a Greek and their "syntaxi"---their retirement check.

No problem...we decided to spend the day in Varkiza, one of the lovely beaches just outside of the city.
Interestingly, despite the palpable anger and frustration (with their own government, not the EU or IMF), we didn't see any picket lines or strikers. The beach, however, was packed with locals who were thrilled to have a day off. Little did we know that this was the 5th national strike since February with the sixth strike scheduled for July 25.

Over the course of the next four weeks, we had many conversations about the financial crisis, and there were two consistent themes regarding the root cause: overspending and fraud.

Overspending

There are many reports that suggest that the 2004 Olympic Games put the country into a downward spiral, and this issue came up frequently in our discussions. Costing $11 billion dollars, in addition to infrastructure costs, this was 50% over budget and clearly more than the country could afford. In our conversations, however, the prevailing perspective was that it was the government's fault.

Maybe so, but there is a long history of overspending, in the form of entitlements, that the country cannot afford to continue but, yet, the people don't want to give up. Did you know:

As a way to stimulate population growth, women who have three or more more children are given a lifetime stipend. One family that we were with has four sons. All are adults, and the mother continues to receives 200 euros per month...forever.
As a way to stimulate tourism, the government established incentives for entrepreneurs to build hotels and open restaurants. And, what a deal! The government gifted--yes, paid for...60% of the development costs for new projects. This helps explains why the islands are lined with large, luxurious hotels with a 57% average hotel occupancy rate.
All employees receive two bonuses a year: a Christmas bonus equal to one month of salary and an Easter bonus equal to two weeks of salary. So, employers are obligated to pay 13.5 months of wages for 12 months of work. Can anyone say pay for performance? Management discretion? Nah..

Fraud

The common enemy among those we spoke to is the 2004-2009 government led by Kostas Karamanlis. "They stole our money! Why should we suffer as a result of those criminals?"

Agree. Many articles describe Karamanlis' reign as corrupt and scandalous with fraudulent financial practices. But, fraud is not limited to the government. Greece has a well-known, long history of tax evasion that costs the country $20.5 billion per year.

While I was well aware of the tax evasion, I didn't realize how much fraud is woven into the country's culture. Defrauding "the system" is not considered unethical, it's how they win. They don't hide it. Rather they brag about it--because it's the norm. We heard several examples that simply made us cringe:

In casual conversation, one gentleman was telling us about his fifteen day hospital stay; the doctor submitted a bill for thirty. One of long time friends, a US citizen, didn't have insurance in Greece but needed Lovenox, an expensive medication to prevent blood clots. She had a doctor write the prescription for her mother, a Greek citizen, who was insured by the national plan. An economist and health care broker estimated that 10% of health care costs are fraudulent.
Business going under? Set it on fire and start over. Arson drives about 20% of fire insurance claims.
It was recently discovered that on top of the 2.6 million people getting a retirement check, there are an additional 160,000 people are on the pension rolls. Here's the problem: they are dead and their families are still cashing the checks.

As a Greek, I deeply disappointed. As a US citizen, I am deeply concerned because it seems that the EU-IMF's rescue loan will only have a sustainable impact if the country's values are re-wired to include personal accountability and integrity. However, in my opinion, the prognosis is dim and, according to Alberto Alesina, a professor of political economy at Harvard, "...what matters is (the) family....there is less of a sense of duty towards the state." (WSJ, 2/10/1010). In other words, less money in the government's pocket means more money in the family's pocket. And, that's what matters most.

The Greeks' unflappable commitment to their families is both their greatest strength and their greatest weakness. Extended families frequently live within steps of each other and eat two meals together...every day. Young adults enjoy spending time with their parents and live at home until they are married. The elderly are included as an important member of the family, and placement of seniors in nursing homes is the exception rather than the rule. It is well known that family connectivity, meaningful conversation, and interacting with people who make us feel loved and appreciated is a key component of longevity. The life expectancy in Greece is 79.8 years versus 78.2 years in the US.

So, what's the bottom line? Take a trip to Greece. Eat a Mediterranean diet. Get up and dance on the tables. Drink ouzo. Take a nap. Watch very carefully how families interact.

Then, come home to the good 'ol USA and incorporate the good that you've learned into your life.

Create Health,
Archelle

Figuring Out A Life-Long Affair

2010-07-27T16:47:00.000-05:00

"Dr G. Any ideas on the best way to lose weight?"
"What do you think about (name the supplement) for losing weight?"

Diet and nutrition questions are some of the most common that I get on Fox. My response always begins with the calorie speech---"In order to lose weight, calories consumed must be less than calories expended." I consistently take a hard stance on the physics of weight loss which makes some people bristle, especially those who believe that their weight issues are hormonal, genetic, or “their metabolism.” I emphasized this very black and white perspective in my February blog, Weight Loss 101: Count Your Calories, where I explained, mathematically, how my own 2-1/2 pound weight loss was fully explained by the energy expenditure of some increased physical activity.

After 7 months, I've lost a total of 7 pounds and the thermogenic reality is a 24,500 calorie deficit. The bigger achievement, however, is the insight into my personal relationship with food.

Hunger does not necessarily mean that my body needs to eat. Emotional-eating has been a way of life for me. I just accepted this behavior as one of my (many) flaws until I learned about the physiologic effects of two hormones that have a powerful influence on the urge to eat—or not. Ghrelin is produced mainly by the stomach and pancreas. Levels are normally high before meals and make us feel hungry. Leptin, its counterpart, is produced by fat cells and causes feelings of satiety and reduces sugar cravings. When leptin levels increase after meals, the brain signals us to stop eating. Here’s the problem: These appetite-controlling hormones are not simply regulated by the body’s nutritional status. Ghrelin (or should I say, gremlin!) levels increase with sleep deprivation. (Maybe this is why I was at my heaviest during my residency?) And, leptin levels, or the body’s sensitivity to it, may diminish in the presence of emotional stress. Just educating myself was enough to give me the willpower to—PAUSE--before reaching for an extra helping or sneaking a second dessert. If I can objectively convince myself that I am calorie-deficient...fine. Open mouth, insert food. However, if I am tired, frustrated, angry or brewing with Greek emotional drama, then instead of using food as a Band-Aid, I try to address the root cause by sleeping, meditating, taking a walk, ….whatever it takes.

You are what you eat. Food Inc. is a 2009 documentary that unveils the secrets of the nation’s food industry and traces the commercial food chain from pasture to pantry. “The Burger That Shattered Her Life” is a New York Times, Pulitzer Prize winning (10/2009) article that exposes the lack of sanitation in the meat industry. Watching and reading these media pieces literally and figuratively made me feel sick to my stomach when I learned how vulnerable we are to e. coli and salmonella contamination. I am still angry at how the industry expertly manipulates our food choices. During the last few months, I naturally found myself making meals with more whole foods, less meat (NO ground beef!) and a minimum of packaged or preserved products. This effortless shift in my preferences was not because of my own discipline or a moral-ethical dilemma but because ingesting food from a box, a can, or a freezer case seems somewhat toxic. Why would I voluntarily choose to feed pesticides, artificial flavors, preservatives, and other unknown ingredients to me and my family?

It’s not “Just Lunch…” it’s an extra 500-700 calories. And, it adds up. There aren’t many benefits to April 15, but preparing my taxes and calculating the totals from all my receipts made me realized how many breakfast and lunch meetings I schedule. Yes, establishing and maintaining relationships is the single most important strategy in consulting, but doing so much business over food is merely a high calorie habit, a security blanket, to ease the discomfort of meeting and engaging with new clients. I decided that having business meetings over a cup of coffee or a glass of wine is just as effective. It’s also cheaper and a more efficient use of time than networking, negotiating, or strategizing over the distractions of a protracted meal.

“Love is never having to say you’re sorry”…and never having to eat more than you want. While business meals have been curtailed, we enjoy going out to eat as a family. It’s an opportunity to be undistracted and completely focused on each other. However, eating in restaurants twice a week was quickly negating the effort of the other five days since I routinely ordered a glass of wine, a salad, entrée, and ate my equal share of the family dessert. Was I hungry for all that? No, but I ate it anyway because I was subconsciously equating the quantity of food I to the quantity of love that I wanted to express. Yes, that’s completely irrational, but so are many of the subconscious beliefs that fuel our behaviors. Some simple self-awareness made it more comfortable for me to order just as much as I want…no more, no less.

While my relationship with food will never be a Love Story, it is a life-long affair. I recognize that “food” is yet another important four-letter word that is an essential part of life. It is a source of physical pleasure and emotional joy as well as a physical vulnerability. Both excess and deprivation are unhealthy, and, for me, achieving some balance required education, awareness, personal insight, and self-confidence.

These are my food insights; what about yours? Why did you just eat that snack or that extra helping? Why did you secretly take the last serving of dessert from the fridge? Why couldn’t you resist eating it? What was the obstacle to saying “I’ve had enough”? The answers aren’t listed on the nutritional label of the food; they are enmeshed in the meaning you have attached to the food. Take some time to understand why you eat. It’s just as important as understanding what you eat.

Create Health,
Archelle

A Perspective on Enron: My Interview with Jeff Skilling

2010-06-14T06:26:00.000-05:00

Everyone knows the story of Enron, or thinks they do. The company started to unravel in March 2001. The collapse, the investigation, and the trial dominated the business headlines until 2006, when Ken Lay and Jeff Skilling were convicted. While I followed the story closely for those five years, my own corporate experiences made me question whether there was another side to this scandal that was not covered in the press. I decided I wanted to hear Skilling's side of the story, and in May 2008, I visited him in jail.

An article describing my four hour conversation with Jeff Skilling is published in Fortune.com. Here is the link: Skilling speaks: Enron CEO's jailhouse interview.

As always, would appreciate your comments.

Archelle

Georgiou's Top 10 Chats

2010-06-08T19:49:00.005-05:00

Every week, after the Fox segment, viewers can “click on the yellow chat bar” and ask me questions online. They can ask any health related question they want, even if its unrelated to the topic I covered on the air.

So, what do people ask a TV doctor? Since my blogs topics have been a little heavy lately…I thought I’d lighten it up a little by sharing the ten funniest or most interesting questions I’ve received over the last two years.

A preamble….
• I am not disclosing confidential patient information. These conversations occur in an online, open chat room.
• The viewers’ chats are verbatim….including the spelling.
• I try to respond to every single question online with evidence-based information. But, in the spirit of brevity, I didn’t include many of my responses in this blog. Too long and too clinical. Instead, I included my “editorial comments” to offer some perspective and food for thought.

OK…here are Dr. G’s Top 10

1) Michelle: "this is rather emabarrassing but lately everytime I have a bowel movement I get super nauseous and end up throwing up. Its absolutely miserable. Please help!"

Editorial Comment: Viewers ask me questions that they are too embarrassed to ask their doctor. One of the saddest interactions was with a woman who was pulling her hair out, due to trichotillomania, and had become reclusive at home.

2) Charles: "I have a problem...That I need help wit. I weigh about ummm around 215 and I was wondering what is the best kind of workouts or diest to help me lose weight...."
Dr. Georgiou: "How tall are you?"
Charles: "Um around 5"8'"
Dr. Georgiou: "Charles, based on your height, your BMI is 32.7. This puts you in the obese category. So, the approach to weight loss that has the most credibility and success is Weight Watchers which combines diet, exercise, accountability, and social support.
Charles: "So what your saying is im fat...."

Editorial Comment: Yup! I am amazed at how often people convince themselves that the BMI definitions of overweight and obesity don’t apply to them.

3) Nicole1855: "is it bad when someone sits on you and it is hard to breath because i am only 10 years old and my mom sits on me but lightly"
Dr. Georgiou: "Nicole, why does your mom sit on you?"
Nicole1855: "cuz my mom wants to sit where i am sitting doc. She wants to use the light"

Editorial Comment: Chatters must be at least 16 years old to participate. While I should have stopped chatting with her when I found out she was ten, I asked her a few more questions to determine whether this was a case of child abuse.

4) Brian: " Are haunted houses healthy to go to?"

Editorial Comment: Brian is a regular, and I can always count on him to ask me questions I’ve never quite thought of before. It’s been heart warming to develop online relationships with other viewers. Shellback is a heart transplant recipient who ended up being a guest on a FoxHealth segment, and Heidi Jo asked me to edit her letter to the Surgeon General. The ones that make me cry are those who have desperately asked for insight on behalf of a family member and then take the time to share news of their loss with me.

5) Mom: "My son only has one eye due to retinoblastoma and he wants to watch the new 3D movies. Is it possible for him to see 3D with the new glasses?"

Editorial Comment: While some questions may seem trivial, they simply reflect how important it is to feel “normal.” In this case, this mom just wanted to get some reassurance that her young son who had an eye cancer might could experience the joys of being a regular kid.

6) Vanessa "Does a dr. ever have the right to yell at a patient?"

Editorial Comment: No, and I am astounded that patients continue to be intimidated by doctors and look for advice on how to interact and communicate.

7) Jill: "My husband snores all the time. He says he dont. I have also thought he has sleep apnea and should maybe have a sleep study. The last 2 nights have been horrible. Im thinkng about getting my own room or the couch. I have looked for the video of your segmant from this morning and cannot find it. Where can i locate this on the site?"

Editorial Comment: It universal…snoring and sex are the two most common complaints women have about their spouses.

8) in-dispare: "my husband and I are trying to have a child. my husband has problems staying erect more than 3 minutes. the doctors said he has ED and can't help him. what can we do? please help."
Dr. Georgiou: "Have you seen a specialist in reproductive medicine or a urologist?"
in-dispare: "No. All the tests we went thru came from recommendation by our fam. doc and whoever else he sent us to. How do we go about getting to a rep med spec or urologist?"
Dr. Georgiou: "TELL (don’t ask) your doctor to give you a referral.”

Editorial Comment: Many viewers don't know where or how to get the care they need. In many cases, they do not feel empowered to ask questions, demand answers and advocate for themselves.

9) Richelle: "low sex driv”
Dr. Georgiou: "Richelle, do you have a specific question?"
Richelle: "I have epilepsy, could my meds have anything to do with my low sex drive? I also believe the sexual abuses I have gone thru in my life could have something to do with it. What do you think? My last abuse was by my father 6 years ago, he was drunk and forced sex on me, I cried the whole time, I have been abused by so many, started at age 5."

Editorial Comment: Sometimes, there isn’t a question to answer. People just need a safe, anonymous place to vent.

10) George: "Hi doc. I just lost 60 pounds. And I am just wondering….where did all the weight go? Did I poop it out?"

Editorial Comment: Needed to end on a light note! I am still laughing.

The online chat is the highlight of each week. It is a chance to interact with real people who have real questions about their health. It is also a continuous reminder that we have a dizzingly complex healthcare system....and I am passionate about doing what I can to fix it.

Create Health,
Archelle

Wisdom or Innocence? Life Through The Eyes A Seven Year Old

2010-05-21T22:21:00.013-05:00

Zoe, our first grader, had a homework assignment this week for her class unit on families. Each child was asked to bring in pictures showing the holidays they celebrate at home. Independent as usual, Zoe ruffled through a series of albums and selected four photos that she wanted to take to school. "These are pictures from our holidays," she announced. "Here's us lighting the menorah for Hanukkah; this was Rosh Hashanah dinner; here's a picture of me with the Passover Seder plate; and here we are on our cruise!"

"Zoe, WHAT are you talking about?" I asked. "Cruises aren't a holiday."

"Yes they are mom. We do it every year. It's a tradition!"

The reflex was to correct her. But, I realized that I was the one who had literally and figuratively missed the boat. I was boxed in to the traditional definition of "holiday" as a religious, cultural or national event. However, Zoe, with her seven years of wisdom, freely interpreted "holidays" as those times when we predictably spend dedicated time together as a family. To her, it is about the experience...not the calendar. Needless to say, she turned in her homework assignment with the pictures she originally selected.

The interaction was an important reminder: words take on the meaning we assign to them.

So, I started thinking about other words that are chock full of boundaries like..."family."

What is family? The Latin term "familia" means household. The first entry in Webster's Dictionary says family is "a group of individuals living under one roof and usually under one head." The Census Bureau defines family as "two or more persons, including the householder, who are related by birth, marriage, or adoption, and who live together as one household.”

Until we leave home in early adulthood, our family--particularly parents and siblings--is our most important and reliable source of guidance, love, and protection. Ideally, our birth family continues to be a source of strength and support for us even as we marry, have our own children, and live under a different roof with our new family. Unfortunately, all too often, the dynamics with our parents are stressful and sibling rivalry re-surfaces. Nevertheless, we generally make great efforts and sacrifices to maintain a connection with the family we grew up with. We forgive, we tolerate, we turn the other cheek, and we try hard to make it work. It’s important.

But why? Why is it important to maintain relationships with parents and siblings? I have asked this question of others and myself over the last year. I couldn't arrive at a logical answer on my own and kept getting answers from others that seemed superficial:

"Because they are family!" Circular logic. Doesn't fly.

"Because blood is thicker than water." Sorry. Last I checked, parents and siblings don't share a common vascular system.

"Because you can't divorce your family." A bit irrelevant. You can't get divorced if you never married them.

It was Laura Engler's response that finally made sense to me: "Archelle, staying connected to family is important because you have shared history. They are the only people who don't need an explanation for a quirk, a family ritual, or an inside joke. They just know."

I got it. Family = those individuals with whom we grow, develop memories, and have trust. If we give ourselves the freedom to transcend the boundaries of the etymologic or legal definitions of "family," then we realize that our dearest friends...are truly family. What a gift! At the same time, blood relatives with whom we no longer have memories, trust, or love...are not. While this perspective may be hard to swallow, accepting and understanding it offers peace and consolation when lifelong bonds are permanently fractured.

This of course leads to more questions: What are the definitions of friend, trust, and love. What about hope, peace, and life? Their meaning is important and very personal to you. Don't passively rely on traditional norms or Webster’s Dictionary. Take the time to remember your experiences around these words. Then, give yourself permission to think and act like a 7 year old who is old enough to be observant and thoughtful while young enough to see the world through a fresh new lens.

Create Health,

Archelle

Why Did They DO That? Unraveling the Actions of the FDA

2010-05-13T14:43:00.001-05:00

On Wednesday, the FDA suddenly decided to impose their regulatory authority on personalized genetic test kits after Walgreens and Pathway Genomics announced they'd be selling them in local pharmacies. But, what triggered this response from the FDA?

Are they new? No. These kits have been available to consumers via the Web for 3 years.
Have they been off the regulatory radar screen? No. As far back as 2008, the rapid emergence of genetic testing fueled the passage of GINA, a federal law prohibiting health insurers and employers from discriminating on the basis of genetic information.
Have these companies been quietly launching their strategy and staying invisible? No. They have made major investments in marketing with an abundant amount of media coverage in women's magazines and news shows.

So, why did the FDA choose to take a stand now?

Maybe the Agency was dealing with higher priority issues. The FDA is busy and constantly putting out other fires, resources are limited, and the number of people buying these kits off the Web has been relatively small. But, with the announcement that kits would available in 6000 local pharmacies, they may have been concerned about a surge in use and the need to fulfill their responsibility to protect the public. A "noble" act, I am sure.

But, were there other underlying forces? Who was nudging the FDA? And, why?

The American Medical Association recommends that "genetic testing only be made available under the supervision of a qualified health care professional."

Hmmm... the most powerful lobbying organization within the traditional medical establishment believes that only clinicians should be the keeper of the keys to our personal DNA information. By the way, does "qualified" include mean nurses, pharmacists, and licensed genetic counselors...or is it really just a code word for "doctors?"

Is the AMA advocating for better health and the rights of consumers, OR...

....Are they trying to maintain a paternalistic status quo?
....Do they feel that doctors are relatively uninformed about the science behind genetic testing and trying to protect them from feeling unqualified to respond to questions when their patients come in with a 77 page report?
....Do they simply want to protect doctors' revenue stream?

I am not picking on doctors...merely the lobbying group that positions itself as a voice for doctors. We should remember that the AMA only represents 29% of US physicians. So, maybe we should listen to the voices of other professional organizations including the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), the Society of Gynecologic Oncologists (SGO), the National Society of Genetic Counselors (NSGC) and the Oncology Nursing Society (ONS) that have more patient-centric positions regarding direct to consumer genetic testing. While all are similar, ONS specifically advocates for pretest education, counseling, and informed consent, with post-test disclosure and follow-up. I would even go further and mandate a telephonic/web based discussion with the certified genetic counselors that are already on staff part of the support team of the genetic testing companies. (FYI, only 10-20% of people currently take advantage of the ready access to genetic counselors. Even as a physician, I found this an important and valuable part of my experience.)

This type of solution would entail a few more steps than the current process which simply requires a credit card and some spit, but it would help assure that people are fully informed. At the same time, it allows the consumer to stay in control and eliminates the additional cost (or profit, depending on what perspective you have) that mandatory physician visits and consultations would incur. In addition, the big 3--Pathway Genomics, Navigenics, and 23andMe--should be able to integrate online education into the patient experience process since each already has elaborate consumer web capabilities.

The managed care industry eliminated doctors as gatekeepers to health care services in 1999. It is now 2010. We don't need doctors as gatekeepers to our own health information.

Create Health,
Archelle

(Note, since this is my 3rd blog on personal genetic testing, I want to re-emphasize that I have no conflict of interest and no business relationship with any of the companies that offer these services. I am simply committed to empowering people to take charge of their health)

When Opposites Attract, We Get Better Health

2010-05-03T15:33:00.001-05:00

Yin versus Yang. East versus West. Technology versus theology. Two Fox topics I covered within a single week were at seemingly opposite ends of the healthcare spectrum. Both were moving. Both made a meaningful difference in peoples lives. Which was better? I was confused…until I started writing the last paragraph of this blog.

Bill Carlson is a 60 year old man that I met online about a year ago during the weekly Fox chat with viewers. “Shellback,” his screen name, signed in every few weeks with progress updates on his recovery from a heart transplant…and then always commented on the wonderful care he received at the University of Minnesota. Since April is National Donate Life Month, I invited him to be a guest on Tuesday, April 20. His story was a medical miracle.

Bill’s congestive heart failure symptoms were easily managed on medication for the first several years that he was diagnosed. Then, in early 2008, his cardiac function quickly deteriorated and by September 2008, he was dying. His ejection fraction was 10%. He had multi-organ failure, gastrointestinal bleeding and was comatose. His family had decided to withdraw life support, but just in time, Bill stabilized and the University surgeons decided to insert an LVAD-- an implanted mechanical pump that helps the ventricle pump blood throughout the body. If it worked, there was a chance he’d survive the wait for a donor heart.

Bill had a cardiac arrest during the LVAD placement. Unable to regain a heart rhythm, the surgeon found the family in the waiting room and told them the bad news: “I am so sorry. We lost Bill on the table.” He sat with Bill’s wife and daughters for a bit then went back into the operating room to finish up. But, he came back twenty minutes later and said, “Don’t go too far. He’s alive again.” For the next nine months, Bill changed his LVAD batteries every four hours, and on June 7, 2009, his cell phone rang. A young man in Pittsburgh had just died. Then next day, Shellback got a new heart.

If Bill had end stage heart failure just five years earlier, he’d wouldn’t be alive. Technology had defied death. This was the yin. Health….from the outside in.
--------

The next Fox segment was on Friday, April 27. I interviewed His Holiness Sri Sri Ravi Shankar, a world-renowned Indian spiritual leader. Through his Art of Living Foundation, he promotes “peace and stress-free living” by teaching millions of people around the world a technique called Sudarshan Kriya. a set of rhythmic breathing processes.

While I am skeptical of Sri Sri’s organization, my preparation for the interview led me to the research behind the health benefits of breathing meditation. Published studies in reputable journals have demonstrated that rhythmic breathing can reduce stress and improve immune function. How does it work? Think about the difference in your breathing pattern when you are scared versus when you are feeling calm. Fast and shallow versus deep and slow. Your emotional state affects your respiratory rate. Conversely, your respiratory rate affects your emotional state by stimulating the nervous system and parts of the brain that control joy, anxiety, calmness, worry, and pleasure. Therefore, voluntarily manipulation of breathing patterns is a “treatment” to address stress….which then affects immune function and the body’s ability to prevent and fight disease.

This was the yang…the body’s innate ability to create health…from the inside out.

In Chinese philosophy, yin and yang are complementary opposites. They co-exist and interact to form a greater whole. Similarly, Westernized healthcare (yin) and mind-body therapies (yang) can and should be used together, as appropriate, to meet the physical, mental, and spiritual needs of an individual. This expanded approach to health and healthcare was a key theme at the Institute of Medicine’s Summit on Integrative Medicine in February, 2009:

“Integrative health care is integrated across approaches to care—e.g., conventional, traditional, alternative, complementary—as the evidence supports. In addition to the best application of conventional allopathic approaches, it may use evidence-based interventions or practices derived from ancient folk practices, cultural-specific sources, contemporary product development, or crafted from a blend of these."

Unfortunately, while clinicians are passionately committed to treating the pathophysiology of an illness, the vast majority are unable, unwilling or uncomfortable addressing the needs of the whole person unless symptoms can be addressed with drugs, radiation or surgery. This mindset is consistent with the NIH definition of Western Medicine and the medical training curriculum that influences how practitioners define their role and responsibilities. Physicians, in particular, are not trained to be responsible for healing; they only feel responsible for treating.

The narrow focus and limitations of Western Medicine also explain why a 2008 report published by the National Center for Health Statistics showed that nearly 40% of American adults use therapies such as yoga, massage, meditation, natural products and supplements. Americans are spending $34 billion in out-of-pocket expenditures for alternatives that help them feel in control, empowered and able to cope. The message is loud and clear: If the medical system doesn’t offer a balanced, harmonious approach, people will find it and finance it on their own because it is essential to healing.

As I was writing this blog and listened more carefully to the elements of Bob Carlson’s story, I realized that both yin and yang were present and equally important elements of his journey. He is one of the lucky few whose doctors recognized the importance of an integrative medicine approach and referred Bob to Second Chance for Life, a support group for heart transplant recipients and people on the waiting list. This is where Bob learned to cope with the fear of organ rejection, the need to respect his donor family’s decision to remain anonymous, and the personality changes that seem to occur when living with another man’s heart.

For Bob Carlson, the Transplant team gave him a new heart, and the support group gave him a new life. Integrative medicine must become mainstream.

Create Health,
Archelle

Stop the Drama and Spit!

2010-04-14T17:47:00.000-05:00

I've been called many names...and, most of the time, I ignore it and let it roll off my back. But last week, I got the ultimate compliment. I was ordained as one of the "Disruptive Women in Healthcare," a blog site that invites anyone, particularly women, to speak up and challenge the health care status quo. Since I got formal permission to be disruptive (as if I really needed to have someone tell me it's okay), I am going to allow myself to be a bit irreverent in this blog entry. I apologize in advance.

The focus of this week's blog is on the health benefits of personal genetic testing--an emerging area of medicine that intrigues many people when they read about it, but scares them too much to get tested themselves. Yes, the blog last week had a similar theme but was centered on the insight you can gain on your ancestral history. In full disclosure, that blog was just a set up; I used a heart-warming, personal story as a first step to getting your buy-in.

The Human Genome Project was completed in 2003, and since then, companies have been springing up that offer personal genetic testing to consumers. The space is dominated by 3 companies: Pathway Genomics, Navigenics, and 23andMe. For anywhere between $350 and $999, testing kits can be purchased without a doctor's order. Unfortunately, even as the price has come down, very few people choose to get their genetic testing done.

Why?

"I don't want find out something I don't want to know." "What if I find out I am higher risk for Lou Gherigs disease?" My personal concern was learning that I might be at higher risk for developing Alzheimers. I was so scared that I stared at the test kit for 3 weeks before I spit into the vial and sent it in. I told my family that the results would come back in 4-6 weeks and the information "had the potential to change our life forever." The drama (which I am pretty good at) was almost worthy of a gold statuette.

But, after going through the entire process, I realize that the worry, the procrastination, and the hand-wringing were wasted energy. The report results were relevant, practical and actionable--TODAY. And, the benefits of knowing my genetic makeup far outweigh the false sense of security that we allow ourselves to experience when we are simply blind to the facts.

The majority of my fears were probably fueled by the unknown: manufacturers' descriptions of report results are vague; I had never met or spoken to someone who had the testing done. So, the goal in sharing my test results with readers in this blog is to dispel some of the mysteriousness of genetic testing and to demonstrate that this important new technology is an easy, cost-effective way to improve health. And, in my opinion, it is the only tool/technology I have seen that might be able to successfully influence behavior.

So, I have one important key message I hope to get across: Knowledge is Power.

The 77 page report I received online was divided into 3 health-related sections: Drug Response, Carrier Status, and Complex Health Conditions.

Drug Response: I had an atypical response to 2 of 9 drugs/therapeutic classes.

1) I metabolize caffeine at a slow rate due to lower levels of the CYP1A2 gene that makes the liver enzyme responsible for caffeine metabolism.

Practical application: Very interesting. This result likely explains why I had a drug reaction to a Midol that I took for the first, and last, time about 6 months ago. Midol, as well as many other OTC drugs (for example, Excedrin and Anacin) contain caffeine. So, no more caffeine-containing drugs for me, and no purchases of OTC meds without checking the ingredient labels first.

2) I have a reduced response to Tamoxifen, a drug used in prevention and treatment of breast cancer.

Practical application: Fortunately, I don't have breast cancer and am not high risk for this diagnosis. But, if I did, tamoxifen wouldn't work particularly well in me. Here's what's scary: genetic testing for the CYP2D6 gene is not routinely done before women are put on tamoxifen. So, there is a population of breast cancer patients who are currently on ineffective therapy...and don't know it. Hello?

Carrier Status: The panel includes testing for 37 carrier states--conditions that can be carried silently in a family for generations, only to be discovered when two carriers have a child with the condition. I am a carrier for hemochromatosis, a liver storage disease.

Practical application: The only carrier state I ever worried about and got tested for when I was pregnant was thalassemia (Mediterranean anemia). But hemochromatosis? News to me! I am completely healthy since there is only one copy of the gene present. Since my reproductive life is over (hallelujah!), there is nothing more for me to do. However, each of our daughters has a 50% chance of having the trait and pre-natal testing for this condition will be critical.

Complex Health Conditions: The panel looks for SNPs, short genetic sequences, that are associated with risk for developing 24 different complex conditions. I have no increased genetic risk for any of them. Just for clarification, these results mean I have average risk, not zero risk.

Practical application: I clearly won the genetic gamble and got a healthy deck by my parents. (Thanks mom and dad!) I found myself making some subtle behavior changes: one less glass of wine, stocking my travel bag with calcium and vitamins so that I don't miss doses when I am traveling--because I feel even more responsible to maintaining a healthy lifestyle.

If, on the other hand, I was at increased risk for any of the conditions, this information would have helped me focus on the prevention, screening and lifestyle choices that mitigate that risk. Without this focus, being "healthy" means complying with a long list of sacrifices:

Eat healthy
Exercise daily
Wear sunscreen
Consume no more than 1-2 alcoholic drinks per day
Avoid red meat
Sleep 7-9 hours per night
Get 15 minutes of sunlight a day
Eat a low cholesterol diet
And on and on.....

Frankly, I can't live in a sterile, sinless bubble. You probably can't either. It's understandable that so many people hopelessly throw in the towel and do nothing. So, for me, the results offer some leeway in those areas where my body might be able to tolerate some extra indulgence.

Convinced?

For those of you who are still uneasy about learning something you don't want to know: Do you avoid having blood tests at your doctor's office because they might diagnose something you don't want to know? Of course not. Why is this different?

For those of you who are nervous about your personal genetic history being on the internet and having your privacy violated: Who really cares about your personal genetic history other than you, your family, and the people that love you? Strangers would much rather know about the details of your bank account.

For those of you who are nervous about your insurance or employer using the information against you: The Genetic Information Nondiscrimination Act (GINA) was signed into law in 2008. It protects Americans against health insurance and employment discrimination based on their genetic information.

So, just do it!
Stop the Drama and Spit!

Create Health,
Archelle

Note: The image in at the top of this blog was provided by Lynn Fellman who creates fine art that is inspired by the science and stories that are revealed by our DNA. More of Lynn's art can be viewed at www.FellmanStudio.com.

Who Are You? You Have A Choice.

2010-04-01T09:28:00.005-05:00

We all enjoy the heart-warming stories of siblings who are separated at birth and miraculously re-connected with each other as adults. We empathize with the need for adopted individuals to search for their biological parents. Why? Because we have an innate need to know who we are, where we came from, and who we are connected to. For the majority of us, our identity is not a gnawing issue. We are surrounded by our parents, siblings and extended families. We are comfortable, sometimes too comfortable, with the personal, cultural and religious labels that our parents bestow on us, and we live our lives believing that we know who we are.

But do we?

As the daughter of Greek immigrants, I always considered myself a thoroughbred. I never questioned my own cultural background, but as far back as I can remember, I was curious about Jews and Judaism. The reality was that I knew nothing about the culture or the religion except that Pikesville, the Jewish neighborhood in Baltimore, was the only area that had a bagel store. I was 24 the first time I entered a synagogue. I felt at home, but it wasn’t about the religious aspects of the service--it was all in Hebrew and I didn’t understand a word. I simply felt a connection to the environment. In 1988, I converted. While the timing centered around our wedding, the decision to take this step seemed completely natural.

It wasn’t until I had personal genetic testing that the pieces of the puzzle fell into place. Mitochondrial DNA from my cheek swab and a saliva sample (I had 2 confirmatory tests because I am compulsive) showed I am in Haplogroup K – a group once found at high frequency in the Basques of northern Spain between 4,000 and 5,000 years ago. My specific haplogroup subtype is K1a5: Seventy percent of the people with my mitochondrial DNA are Ashkenazic Jews. Relatives who have done some additional genealogy research discovered that my maternal grandmother’s family, named “Leventis,” were previously named “Levin.” Six hundred years ago, the family was most likely from Spain but migrated to Greece after the Inquisition in 1492. They assimilated….became Hellenicized…and the rest is accurately captured in “My Big Fat Greek Wedding.”

I finally understand the quirkiness in how I was raised….why my mother only emphasized a belief in God (vs the Holy Trinity) and never served a pork loin. I feel “related” to my husband, his family and a people that I have been emotionally connected to throughout my life. Do I feel any less Greek? Of course not. But, I do have a new sense of wholeness because “they” are me.

As many of us celebrate Passover and/or Easter this week, remember that “they” could be you. Whether you explore your roots through stories, historical research or genetics, the knowledge you gain helps you deepen your understanding of yourself. Too often, we don’t question who we are. We don’t challenge or debate the status quo. But, if you take the time--and have the courage--to analyze, interpret, and making meaning of the origin of your values, beliefs, and traditions, you will have the opportunity to actively choose who you are. And, if you give yourself the freedom to embrace those beliefs that “fit” and distance yourself from those that don’t, you can honor your past while being true to yourself. Happy Holidays.

Create Health,
Archelle

Need Therapy? Have An Oreo.

2010-03-23T15:00:00.006-05:00

During a recent family dinner, we stumbled on the topic of Oreos. We each took turns giving a detailed description of how we eat these blissful, crème-filled chocolate biscuit sandwich cookies. In 20-30 minutes, the discussion gave us more insight into each other than I imagine we’d get from 6 months of family therapy.

Here is the rundown:

Zoe (age 7) just eats the Oreo--as is.

David (58) and I (47) twist the Oreo apart. I eat the plain chocolate biscuit first and then the half covered with crème. David, on the other hand, eats the plain biscuit, licks the cream off the other half, and finally eats the remaining chocolate disc.

Athena (17) has a process that requires 2 Oreos at a time. She twists apart each sandwich and eats the 2 plain halves. Then she puts the two crème-topped halves together and, VOILA! she has a Double Stuf Oreo. (No, that’s not a typo.)

Arielle (20) twists apart an Oreo and immediately eats the crème-topped half. Then she twists apart a second Oreo and eats the crème-topped half. This goes on until she either runs out of cookies or feels guilty for eating too much. Left with a pile of chocolate biscuit evidence, she assembles “new” Oreos, substituting peanut butter for the crème and carefully placing them back in the original package. She quickly heads to the grocery store, gets a fresh new package of cookies that she doesn’t dare touch and replaces the half-eaten package.

So, what’s the interpretation? If you make a basic assumption that the chocolate biscuit is less desirable than the creme filling…

Zoe is simple and straightforward. She doesn’t overthink a situation or read between the lines (or the cookies.) In her world, what you see is what you get. This is consistent with her age, but it doesn’t imply that someone who eats an Oreo “as is” is childish or that they lack depth. Rather, it suggests that they are honest, direct, and loyal.

David and I don’t take the cookie, or any life situation, at face value. We dissect it to understand its risks and benefits. Yes, we approach our Oreos and our lives similarly, but there is a subtle but important difference: David spends more time analyzing…whereas I jump to a conclusion a little faster. And, while I end the process on a positive (crème-y) note, David ends with some crumbly chocolate and healthy skepticism. Opposites definitely attract.

Athena is focused and keeps her eye on the goal. She is willing to pay her dues (and eat her chocolate cookies) up front in anticipation of receiving a big reward on the back end. Maybe this explains why she wakes up at an ungodly hour on weekends to snowboard in sub-zero temperature. Her reward comes at the end of the season when she has practiced enough to gracefully ride a half-pipe and successfully land a 180 degree turn. The examples are endless.

And, Arielle…

The discussion crystallized my understanding of her personality. When she is passionate about an issue (or crème filling), she must have it; ”No” is not part of her vocabulary. Example: NYU doesn’t have an exchange program in China? Not a barrier. She petitioned the Dean until he said okay. While she allows herself to devour the joy of the moment, she also makes sure that it is not at the expense of others. Her zest for life is infectious.

How accurate is the psychological interpretation of our Oreo consumption? Who knows. There are many sites on the Web claiming that “psychologists have discovered that the manner in which people eat Oreo cookies provides great insight into their personalities.” However, I cannot find the original source, and, to be honest, it doesn’t even matter. What matters is that our family had a fun and creative conversation. The cookie metaphor made it simple for all of us (even Zoe) to understand that we each attack life (and food) in uniquely different, but equally satisfying and valid ways. We laughed, we argued, we debated, … we connected and communicated with each other. Isn’t that what therapy does?

So, which you rather pay?

$ 3.99 (cost of an 18 oz package of Oreos)
or
$ 1200 (cost of bi-weekly family therapy sessions for 6 months)

Go ahead…have an Oreo. And whether you bite it, lick it, twist it, or dunk it…take the time to talk about it…with the people you love.

Create Health,
Archelle

Code Blue in the News Room

2010-03-10T12:22:00.001-06:00

Power: On
Remote: In hand
Channel: News (pick your favorite)

Magically, from the comfort of your home, a reporter appears on the screen and you hear information about a breaking news story. Effortless for viewers (as long as electricity and cable bills are paid.) Not effortless for the news station.

Every Tuesday and Wednesday, I stroll into Fox sometime between 7:30-9 am. I just need to be there 15 minutes before my segment. A skeleton crew produces the morning show; they are always a little bleary-eyed since they work overnight to write content, design graphics, load the teleprompters, and make sure story transitions make sense. The producers cross their fingers that guests arrive on time so they can get them mic'd up and shuttled into the green room. Anchors, Tom Butler and Alix Kendall, are responsible for making sure that you can "Wake Up With Fox 9." Keith Marler is funny both on and off camera. There is a consistent, quiet (except for Keith) rhythm to the activity in the station. Five days a week, this crew produces a 5 hour morning news show...and it happens like clockwork.

Yesterday, I saw a different side to the news. I found myself in the station at the beginning of a breaking news story. I got out of the way and watched as the team went into action. There was an eerie similarity to what happens when a hospital loud speaker goes off with the words, "Code Blue."

It was about 9:59 am, and Matt, the executive producer, was just starting to take a deep breath as the morning's program was coming to an end. Before he could exhale and relax, the person monitoring the desk called out:

"BREAKING NEWS STORY! Minneapolis Schools are on lock down. Don't know any details."

There was a moment of suspended animation as everyone stopped to listen before they sprinted into action. It was the same pause that occurs between the moment that the Code Team beepers go off and when everyone leaps into action and runs through the hallways to get to the patient's room.

Matt went into high gear. First things first....get a reporter to the scene. (Get to the patient--STAT!) Wait...where the heck is the scene? Which reporter is the best one to take this on? Who is closest? Get to Northeast Minneapolis! (Which bed--which patient? Who is on call? Get Cardiology to 5 North!)

Kelly, the assignment manager, and Lori, the evening producer, focused on gathering clues and details. The phone kept ringing with news tips, but within a few minutes the desk received an official report that the Minneapolis police received a message that a man was threatening to go to an undisclosed Minneapolis public school, shoot, and then shoot himself. The threat may have been on a social networking site. Was it on Facebook, MySpace, both? They also learned that one St. Paul school was on lock down. Why just one? Was this a separate incident or are the lockdowns related? (Vitals check! What's the patient's rhythm? Get a hematocrit! What do we think is going on? Did the patient have an MI or are they bleeding post op? Call Surgery!)

Bill Dallman, the VP, (aka, the guy in charge) was standing in the middle of the studio...observing...as his team was coordinating deploying film trucks and reporters, writing scripts, and gathering facts. Everyone looked to Bill to make the important decision: "When do we cut?" Translation: When do we have enough information to justify interrupting regular programming to broadcast a Breaking News Update?" (When do we operate?) Bill made the call, "We're ready. We're going live." (Chief says, "Get the OR ready.")

Within minutes, the Bonnie Hunt Show was interrupted. Tom anchored the segment even thought he would normally be going home after the morning broadcast. Both he and Alix committed to being available to anchor the ongoing updates until the evening anchor team arrived. (Being "off call" is irrelevant if there is a patient to stabilize.) Jeff Goldberg reported from the scene using his cell phone--no satellite, no video--since a cameraman was not able to arrive in time. (Use what you have available. If you don't have the right clamp, a small hemastat will do.)

The first breaking news report was done. Jeff was assigned to gather ongoing facts from the field and more updates would be posted on the Web with a tentative plan to do the next broadcast update at noon. (Monitor the patient in the ICU.) With the Bonnie Hunt Show back on the air and a temporary lull in the activity, Kelly decided that in the future all the reporters should have an iPhone application that would allow them to transmit video in a pinch. This was process improvement happening right in front of me.

During the three years I have worked with Fox, I have felt like an outsider. Not because the team hasn't been inviting, but because their priorities--ratings, programming, sponsors, High Def--are all relatively foreign to me. I had convinced myself that they are true media professionals, and I am just a clinical professional in a media world. But, yesterday, I felt at home.

The stress and adrenaline rush of a potential crisis gave me a peak inside the DNA of people in the profession. Their passion wasn't driven by ego, the need to sensationalize, or competitiveness with other networks. At their core, what really turns them on is the pursuit of facts and information and getting it out to the public in a way that balances speed and accuracy. (Hmm...sounds like quality and efficiency.)

My passion is health and healthcare; the media's passion is information and communication. It doesn't seem so different anymore--as long as we all love what we do.

Create Health,
Archelle

Lights, Camera…Fight Fraud in Health Care AND In Congress

2010-03-07T13:13:00.000-06:00

There was speculation that the Health Care Summit hosted by President Obama would be a Kabuki Dance or a highly staged photo opportunity. Instead, the seven hour event ended up being a good forum for debate. There was no “Minnesota Nice” as both sides openly expressed their views on health reform. And, while there were some long-winded anecdotes, many of the attendees focused on having a data-driven discussion. Most importantly, the cameras offered some clues on how nonsensical and expensive provisions get incorporated into legislation.

Republican Senator Tom Coburn, a physician, started off strong when he boldly stated that the nation needs to address the escalating costs of health care before expanding access to 30 million additional Americans. He raised the issue of rampant fraud in the system, estimated to cost the $60 billion a year in Medicare alone.

But, his comments took a bad turn when he said, “In your new bill, you have good fraud programs, but you lack the biggest thing to do. The biggest thing on fraud is to have undercover patients so that people know we’re checking on whether or not this is a legitimate bill.”

Obama scribbled some notes, and subsequent news reports highlighted Coburn’s idea as one of the few common areas of agreement. In the President’s follow up letter to Congressional leaders on March 2, he included undercover patients as one of four good ideas that he is willing to integrate into his plan.

Deploying "mystery shoppers" may be useful in highly targeted situations when a thief must be caught red-handed for a quick prosecution. Otherwise, this is an archaic and expensive approach for identifying fraud. Unless there is blatant illegal activity, such as billing for a deceased patient or billing for tests and visits never performed, it requires multiple visits to prove that unnecessary or inappropriate services are repeatedly and systematically rendered.

This approach is neither scalable nor efficient. Organizing a field force of hundreds of secret shoppers would certainly result in yet another department within HHS with its own separate budget. The operational infrastructure would require extensive training, databases, and processes to “review the reviewers” so that inter-rater reliability is minimized and the conclusions are credible. Many of us reading this blog have lived through the expense and inefficiency of conducting onsite HEDIS chart reviews where individuals trained in chart abstraction visited doctors' offices to manually document that preventive services were delivered to patients. Designing and implementing an onsite federal program to detect fraud would be exponentially more complex.

One could also argue that a system that depolys secret shoppers is unethical since these visits consume valuable doctor-patient capacity that would otherwise be used for real patients with real illness. And, consider the intrusiveness and anxiety among the innocent high quality doctors that are randomly selected to be reviewed. Will these doctors be reimbursed the lost income resulting from one of these visits?

Obama is unquestionably tech-savvy. A few days before the Summit, he released his proposal for health reform that outlined some new and aggressive proposals to fight waste and abuse such as a “Comprehensive Sanctions Database” and “Use of Technology for Real-Time Data Review.” These investments would result in continuous national surveillance of claims activity looking for patterns of utilization and billing that suggest fraud. The banking industry has been doing this for years.

So, why did he support a 1980’s solution that is unlikely to drive a meaningful difference in reducing fraud but creates more bureaucracy and costs more money? I suspect he thought if would be good politics... since it clearly doesn’t fall into the category of good or smart policy. Whatever the reason, the good news is that the live coverage of the Summit created broad awareness of this issue that can now be part of the debate. And, its an important reminder that “behind closed doors” debate makes it a little too easy to include language that unfairly benefits special interest groups. Need I remind you of the:

• “Cornhusker Kickback” provision giving Nebraska permanent and full federal aid for his state's expanded Medicaid population.
• “Louisiana Purchase” provision giving between $100 million and $300 million in additional federal aid for the state's Medicaid population.
• Medicare Advantage protections in Florida, New York, and Pennsylvania.
• Special tax exemptions for auto-unions.

How many more of these special interests are lurking? Who knows, but Minnesota’s own, Senator Amy Klobuchar, said, “People fight for their own states. That's the nature of a democracy."

No, Senator Klobuchar, back room deals are not democracy. They are tantamount to fraud.

Lets eliminate fraud in the health care system and in Congress. We don’t need to start the whole process over, but, we need a line by line review of the language with the camera’s rolling. We need Congress to be as accountable as we expect doctors to be.

Create Health,
Archelle

Weight Loss 101: Count Your Calories

2010-02-15T10:51:00.000-06:00

On February 9, 2010, First Lady Michelle Obama launched the "Lets Move" campaign that focuses on decreasing childhood obesity. The strategy she laid out includes:
• improving nutrition and physical education in schools;
• promoting activity such as walking and biking in community planning;
• making healthy food more available, particularly in poor areas; and
• making nutrition information on food packages clearer.

These approaches make great sense, but I worry that they dance around the most basic element of achieving weight loss: counting calories.

One of the most common questions I get during the Fox online chat is:

"Dr G: I need to lose weight. Any recommendations?" My response is typically:

"Loyal Viewer...Losing weight is all about burning more calories than you consume. You have to have a deficit of 3600 calories to lose 1 pound.”

Yes, there are many techniques that I recommend that can help support a weight loss program:
• Write down everything you eat: People who keep a food diary lose twice as much weight as those who don’t
• Weigh yourself daily: Especially important for weight maintenance. People who are aware of their weight will be more conscious of addressing it when it begins creeps up instead of suddenly finding themselves 20 pounds and 2 sizes heavier.
• Exercise at least 30 minutes 5 times a week. Need I explain the benefits for weight and overall health?
• Eat breakfast: Individuals who eat a high fiber, high protein breakfast are more successful at weight loss than those who don’t eat breakfast.

But, I always circle back to the bottom line: 3600 calories = 1 pound. There is no magic bullet.

Focusing on eating healthy, nutritious foods is certainly important. But, it is also important to understand that eating too much of a good thing translates into gaining weight. In 1990, the Federal Government triggered the low fat craze by suggesting that the American diet should have < 30% fat. Fat consumption dropped 17.5% but obesity increased by 25%. Why? Americans overate low fat foods. The same risk is present with the current focus on eliminating transfats. There is a common misperception that eliminating transfats is good for your heart and your weight . In reality, foods without transfats are frequently higher calorie because of added sugar (and calories) to compensate for taste.

Let me make the case for counting calories:

Since transitioning from a corporate office to a home work environment in 2008, I worked harder and longer, but I wasn't moving as much and it caught up with me. My clothes got a touch tighter and while my family said “you look great, Mom” the scale was the ultimate source of truth. In January, I joined the millions of Americans who make a resolution to lose weight, and I committed to getting back into a daily treadmill routine. I bought a pedometer to help keep me accountable.

As of February 14, I had lost 2-1/2 pounds.

So, some straightforward math:

Pre-January average number of steps per day: 1,500
Post-January average number of steps per day in Jan: 8,000
Incremental steps per day: 6,500
Total additional steps in 45 days: 292,500

My stride is 1.7 feet which means that 3,168 steps = 1 mile
Therefore, I walked 92.3 miles during this time
Since 1 mile = 100 calories, I burned an additional 9,232 calories

=2.56 pounds

How many times have we heard (or said) "I just can't lose weight. No matter what I do or how little I eat, I can't do it." Sorry folks. Unless you are one of the rare individuals with a metabolic disorder, you are simply eating more than you are burning.

While we are born with the innate ability to regulate our calorie consumption relative to our energy needs, by the time we reach adulthood, we eat for many reasons unrelated to hunger. Therefore, consciously counting calories is essential to maintaining a normal weight. Messages and strategies that de-emphasize the frank reality of total calories consumed versus total calories burned puts the public, and our kids, at risk for getting fat.

Create Health,
Archelle

Power of One

2010-02-06T11:47:00.000-06:00

"Game Change" the new book about the 2008 presidential election has topped the New York Times Best Seller List for the last three weeks. The book has stirred alot of controversy since it relies exclusively on anonymous sources. Nevertheless, I was thrilled to get a copy of this gossipy, tell-all book about behind the scenes events on the campaign trail. What could be better? The only books juicier than trashy fiction are books that are trashy non-fiction.

But besides offering airplane entertainment, Game Change stimulated my thinking about the power and the influence of a single individual. Barack Obama, despite a lack of experience and a traditional political financial engine, believed that he could capture the single moment in time when he could create hope in America. Regardless of whether you voted for Obama (I didn't) or think that he has been successful during his first year (I don't), he did win the presidency on the belief and the passion that he, himself, could drive a change in the nation.

Similarly, Oprah is committed to decreasing the number of accidents caused by cell phone distractions. She launched the No Phone Zone movement on her January 18 show and since then, 106,410 people have signed a pledge. The numbers increase daily, and given the Queen of Television's track record, I predict that Oprah will have more impact on this issue than any regulation or policy that might be enacted.

So, what is unique about individuals who believe that they can single-handedly make the world a better place? What is the driving force that gives them the energy and the optimism to tackle challenges that so many others view as insurmountable? It is easy and tempting to dismiss their drive to having the perfect combination of narcissism, money, and celebrity status. It is also short-sighted...because there are ordinary people all around us who have an extraordinary and relentless commitment to make a meaningful difference in the world.

Dr. Michel Mirowski, was a holocaust survivor, a cardiologist, and the father of a fellow med student. In 1966, Dr. Mirowski was having dinner with his mentor who died at the table. For the rest of two decades, Michel Mirowski committed his career to finding a solution to Sudden Cardiac Arrest. Despite considerable controversy, in 1980, he invented the first Automatic Implantable Defibrillator--one of the 20 most important contributions to cardiology.

Michelle Robson, a former model, found herself debilitated with a serious medical illness at the age of 42. After numerous hospitalizations but no diagnosis or prognosis, her frustration in navigating the health care system made her contemplate taking her own life. She recovered, and in 2007, she founded EmpowHER.com, a free health health resource site so that she could help make sure that other women don't have to struggle as much as she did to get the care they need. The site currently receives over 500,000 web hits per month.

Laura Engler is a dear friend whose family was impacted by the Madoff scandal. According to her own account, "we are unequivocally and un-apologetically nouveau poor. Our 401(k)s are now 201(k)s....And, whether because of a Ponzi scheme, the sub-prime mortgage crisis or the overall global economic downturn, thousands of formerly well-to-do Americans are in the same boat." Instead of "oh poor me," Laura and her daughters launched NouveauPoor.com "to help people of all ages embrace this new reality with style, grace and humor."

So, what is the common theme? From Barack Obama to Laura Engler--they all overcame adversity. In addition, they translated the adversity into a passion and a solution that would help others who might be facing a similar situation. How did they harness the energy to turn it into a positive? To some extent, our personality influences how we respond to adversity but our response is also a choice. We can either be a victim or a victor of circumstances.

Too often, we allow ourselves to get caught in thinking that "Bad Thing Happen to Good People." Instead, we can choose to believe that "Bad Thing Happen to Good People--And It Can Have A Good Outcome" And, in fact, there are well-documented benefits to adversity.

Dr. Sharon Parks, a Harvard professor, identified that experiencing adversity is a critical element for effective leadership. It not only fuels passion but it helps to develop the moral-ethical maturity of an individual and builds resilience. Adversity, or "cognitive dissonance" is a catalyst for innovative thinking and richer, more complex ways of understanding others. Without conflict and struggle, our moral reasoning gets stuck at conventional and conformist levels of thinking.

None of us live a life without adversity; some of us simply have more than others. As I recently said to a friend, "Shit happens. It all about how you recover."

Create Health,
Archelle

Health: Its Greek To Me

2010-01-26T22:04:00.000-06:00

What do Sally Field and I have in common?
No. I never aspired to be or play a nun.
No. I didn't co-star with Robin Williams.

Answer: We are both on Boniva.

Last week, during my annual ob-gyn appointment (clarification: it was all gyn, no OB for me!) I had a follow up bone densitometry test. Since the scan that I had 2 years ago showed bone loss, I was anxious to see if there was any progression. There was; it was significant.

My reaction was interesting. I got a lump in my stomach. (Code word: I panicked.) I was scared of falling on the ice when I walked out to the parking lot. I stopped by Target to get Viactiv and then by the grocery store to get yogurt and cottage cheese. When I got home, I immediately popped 2 of the chalky chocolate chews, 2 magnesium pills, and searched my contact list for the phone number of Dr. Felicia Cosman, a national expert on osteoporosis. I wanted a second opinion.

But, as I stepped outside myself, I started wondering, "Archelle, why are you so surprised?" I have a strong family history of osteoporosis, didn't exercise until I was 44, have refused to take calcium because it makes me constipated, and only added dairy products and Vitamin D to my diet over the last few years. In fact, just a few months ago, I was a spokesperson for the National Osteoporosis Foundation. Yes, I knew better so what outcome was I really expecting? Was I hoping that I would defy the odds? Or, was I in denial? Maybe a little of both.

I was even more intrigued by thinking about what triggered an instantaneous change in my behavior and got me motivated to take actions that I had postponed for all of my adult life. The only thing that really changed between 2:15 and 3:15 pm on January 21 was a diagnosis. No pain. No fractures. No symptoms. Just a diagnosis...

Receiving a diagnosis is a known influence of behavior change even in the absence of new physical symptoms or function, and studies have shown that adults with new diagnoses are more likely to adopt healthier habits. How many times have you heard about a chain smoker suddenly kicking the habit when diagnosed with heart disease?

But, fundamentally, a diagnosis is merely language. So, how do the words have such a powerful influence on behavior? Language stimulates our brain to creates strong emotions and vivid images that change how we see ourselves and our sense of identity. Think about the hearing:

"You are pregnant."
"You have cancer."

In a split second, these words change our reality. And, it is only when our reality changes that we are motivated to change our behavior. The English language has a 16,000+ word vocabulary for disease but only 4 words describing health: healthy, well-functioning, fit and normal. Bone disease, for example, can include osteopenia, osteoporosis, osteosclerosis, osteochondroma, and osteosarcoma. However, non-diseased bones can only be described as "healthy bones." Heart disease can include cardiomyopathy, coronary atherosclerosis, and hypertension, but, a non-diseased heart can only be described as a "healthy heart."

The paucity of a language of health may help explain our reactive disease-focused culture: since there is no language...there is no change in reality. When there is no change in reality...there is very little drive to modify behavior.

We need to expand the vocabulary for "health" to help motivate positive lifestyle changes. However, given the state of the union and Obama's State of the Union, it is unlikely that we will see language reform within health reform anytime soon. In the mean time, I will look to the Greek language for guidance since it already makes up 75% of existing medical terminology.

Since our three daughters are at high risk for osteoporosis, but have ample time to do something about it, I am going to invent a new diagnosis for them: osteodynamia (osteo- bone, dynami- strong) and give them a prescription:

--Regular exercise: weight-bearing and strengthening exercise
--Calcium: 1000 mg/day
--Vitamin D: 400-800 IU per day

Hopefully this "condition" and treatment plan will create a new reality that inspires them to have the lifestyle behaviors that I avoided for 30 years. Take a shot a diagnosing yourself with a new condition that will motivate you. Don't know Greek? Here is a link to help you get started.

Stay Well,
Archelle

Unleash Your Potential

2010-01-20T17:52:00.000-06:00

I had a hard time writing this week's blog entry. Not because there was a lack of interesting news. The medical stories out of Haiti are heart wrenching. The "behind closed doors" health reform compromises coming out of Capitol Hill are a good reminder of the differences between policy and politics. And, my on-line chat conversation highlighted the lack of awareness of the transmission and dangers of Hepatitis C.

Nevertheless, I found myself struggling to identify a topic where I could offer a unique perspective that was both inspiring for me and worthy of your time. My circuits were down. So, instead of fabricating a topic and trying to develop an angle that would be a yawn, I decided to write about the genesis of creative ideas because, frankly, I wanted to figure out what the heck happened to mine!

Where do "AHA" moments come from? "Where is a thought before you have it?" This is the question that Deepak Chopra asks his audience before launching into a complex explanation that weaves together biology, quantum physics, and spirituality. The simple explanation (for those of you who are not new age groupies) is that a concrete thought is housed in the brain. However, the precursor to a thought (the pre-AHA moment) exists somewhere outside of the brain and the body. Chopra suggests that this energy is the source of our creativity; it is our potential.

So, how does one tap into this potential and translate it into new ideas? It starts by being thought-less. Each day, the average brain is consumed by 60-80,000 mundane and reactive thoughts. Since the brain can only have a single thought at a time, it is only open to new inspiration and new thoughts when it has capacity... that means getting rid of unnecessary distractions. Whether you buy into this theory or not, think about how many times you have come up with a brilliant thought "popping" into your head while in the shower or when dozing off to sleep. Your AHA moment occurred when your brain was quiet and doing nothing. Alternatively, how many times has that moment of brilliance occurred during a corporate brainstorming meeting? Point made?

It is the lack of stillness that interfered with my own creative thinking this week. I was playing catch-up from the holidays, our daughter, Arielle, was home from college, and we are in the midst of a transition to a nanny-less household. As a result, showers were cut short, exercise time evaporated, laundry was accumulating and sleep was more like being in a coma. While the family and work dynamics were wonderful, I was "on" for weeks, and there has been no time to ponder, imagine, or think.

It won't take long to get find a balanced, stable hum (or should I say, "OM") that works for me. In contrast, the emerging generation of adults--our "kids"---do not strive for stillness. They believe they are energized by the exact opposite, and they strive for continuous connectivity, stimulation, and interaction. Sherry Turkle, a professor who studies social networking at MIT says, "If you’re being deluged by constant communication, the pressure to answer immediately is quite high. So if you’re in the middle of a thought, forget it.”

When do kids have time to think? Or do they?

I recently worked with a group of college students who completed a series of research projects in 5 days. In 1981, it would have taken an entire semester. Clearly, the technology and their expertise in using it gives them unprecedented access to relevant information on the Web..at lightening speed. As a result, they have a learning trajectory that is steep and compressed. While I admired their efficient assimilation of information, I also observed that they didn't formulate any unique opinions or offer an analysis. Yes, the technology is making them smarter, but is it simultaneously limiting their opportunity to make new and unique contributions by eliminating time to simply be still and alone?

I worry that this "new normal" of 24/7 connectedness will lead to a decline in the number of new inventions, new concepts, and new design. I worry even more that upcoming generations will not be personally fulfilled if their accomplishments simply revolve around summarizing and repackaging existing knowledge. The human spirit wants to create, ideate, and innovate. Human beings want to tap into their own potential--not only the potential of others.

As for me, I am glad that this week's blog is written and published. The topic made me realize how much more productive I am when I do nothing...because it is when I can make the most meaningful contributions professionally and personally. So, Arielle is back in New York, I have a better process for getting the laundry done, and I have to start figuring out my blog topic for next week. I think I'll go take a shower.

Create Health,
Archelle

When More Traffic Is Good For Your Health

2010-01-10T15:12:00.000-06:00

There are 200 million Americans online and over half use social networking sites. Facebook has over 56 million US users; 350 million worldwide. Twitter has about 18 million US users and it was just launched in 2006.

It's mind-boggling. But even more mind-boggling is the low adoption rate of Web sites that could make a significant difference in the quality of care that people get from doctors and hospitals. Published studies repeatedly show that all providers are not created equally, and only 50% of care is consistent with evidence-based standards. And, even though there are countless publicly available web sites that offer a "report card" of results for doctors and hospitals, less than 5% of US adults use data to help select their care providers. HealthGrades.com is one of the most established sites for health care quality statistics. Traffic to HealthGrades is 1/10th that of Yelp.com, a popular site with reviews of restaurants, hair stylists, mechanics, etc. Traffic to other sites, including CMS’s HospitalCompare, and the New York Times site, UCompareHealthCare, are even lower.

I was familiar with these statistics but was convinced that the underlying reason was that existing websites are too complex for the average American consumer. I experienced this myself when my mother-in-law needed heart valve surgery. It took me endless hours of research on the Web to scour through complication and mortality data, put it in a spreadsheet and analyze it. The effort was worthwhile; we selected a hospital that did twice as many cardiac surgery cases and had significantly better outcomes. After that experience, however, I thought, "If this process was hard for me, imagine how hard it is for someone who is not a doctor and a data geek."

A year later, I launched www.myhealthcompare.com, a free, no ad, easy to use site that simply answers the question that someone has when faced with choosing a hospital: "Where is the hospital where am I most likely to get the highest quality care.?" The feedback has been overwhelmingly positive: the methodology is credible, the navigation is intuitive, and users say that the comparison rankings are straightforward. Tunheim Partners surrounded the launch with a national press release and media campaign; Newt Gingrich tweeted about the site to his 1 million followers, and CNN.com linked to the site in its year end article, "Top Empowered Patient Tips for 2010." Despite the visibility and media attention, the challenge of driving traffic to the site is harder than I ever expected.

I have spoken to viewers, friends, relatives, colleagues, and even random people in Starbucks about whether they use the Web to "check out" their doctor or hospital.
The unanimous response: No.

"I didn't know that this type of information existed." Lack of awareness is a significant issue; individuals simply don't know that data is available and credible.

"My insurance will only cover certain providers." The complexity of the health care system drives this misperception. The reality is that insurance companies contract with an array of providers and a there is a fair degree of choice within a network.

"When I look at restaurant reviews, I know what’s important tome. If I look at medical data, I wouldn’t know what to look for.” This response speaks to the importance of translating data into information that is relevant and comprehensible.

Increasing awareness, explaining the ins and outs of insurance, and simplifying how data is presented and formatted are relatively easy solutions to these adoption barriers. It just takes time and money. So, I pressed further. "But, what if these barriers were eliminated? Would you use the data to help you figure out where to get your care?"

The responses reflected issues that may be at the core of the low adoption rates.

Trust: "I don't want to switch doctors...and this is the hospital that my doctor recommends." We still have a culture that positions the doctor as being an authority figure that cannot be questioned.

Faith: "Our local hospital is really good, and I just believe that everything will be okay. If something bad happens, it’s probably just meant to be.” Even when I mentioned that there are 439 hospitals in communities across the US with quality of care that is below average, I sensed an insurmountable need to believe in utopia and fatalism.

Risk: "If I use data to make a decision about my health, then I am responsible. What if I am wrong? It's easier to let someone else tell me where to go and what to do."

There were clearly religious undertones. While my conversations were anecdotal, what I heard was consistent with the results of the World Values Survey: the US is highly traditional on the “secular-rational spectrum.” We are both a religious society and one that emphasizes the importance of paternalistic relationships and deference to authority. We dutifully listen to our parents, our pastors....and our providers.

Too often, we seem to approach our health the way we approach our spiritual beliefs: with unquestioning faith. But, I propose that asking questions and acquiring knowledge can meaningfully deepen and enhance one’s experience and outcomes in both religion and in health.

To you, the reader: Will you ever spend as much time researching the care you receive as the time you spend researching the hotels that you stay in and the restaurants you eat in? What will it take for you to make it a priority to use objective data before you see a new doctor or schedule an elective surgery? What will will it take to make you a good health care consumer?

I look forward to your thoughts and comments.

Create Health,
Archelle

Make A Toast To Love in 2010

2009-12-24T10:17:00.000-06:00

It's the holiday season. Love is in the air and sex is in the news. During the last several weeks, I've talked about studies showing that

--40% of teenagers have sex before their parents talk to them about the birds and the bees.
--Sexually active young adults believe in planned pregnancy, but half of them don't use contraception consistently, and
--One in four between ages 14-19 have at least one sexually transmitted disease.

And, yes, I even used the Tiger Woods story as an opportunity to segue into a segment on sex addiction.

During the online chat, I expected to hear complaints from viewers who were offended by my use of the words "pornography" and "phone sex" in a morning news program when kids are watching. I also expected to get emails from parents asking questions about when and how to talk to their children about sex.

Instead, I got questions from women struggling with and asking for personal advice about their relationships.

Chatter: "I think my boyfriend has a sexual addiction. Here's the kicker - he's bi, and keeps wanting and having sex with guys on the side. Our biggest issue is whether this is cheating or not - something we can't agree on. He would never think of sleeping with another woman, only a man. What do you think?"

My Response: "You shouldn't feel that you have to negotiate on how you feel about fidelity. This is a core value. And, if it is as misaligned as it sounds, you may be in the wrong relationship."

The chatter abruptly dropped off. Another chatter who called herself Searching4Answers asked:

"My husband acted out a couple of years ago and I'm still trying to deal with it. He had sexual contact with anonymous males who pursued him online. He met with them and they performed acts on him but there was no intercourse. We are in couples therapy, but my husband wants everything to go away and not deal with the conflicts and problems. How do we repair our relationship?"

Her despair was palpable.

While the circumstances in these online conversations are somewhat extreme, the underlying theme is common: women (and sometimes, men) will make the relationship work at all costs. A dear friend has felt ignored for years and yet, she wants to "give it one more year." Another feels invisible and de-valued but accepts that it will simply be like this forever. They are committed to the marriage, but the price they pay while trying to maintain stability is being emotionally unfulfilled. Why are they uncommitted to themselves? In both situations, the answer is “the relationship is good.” This is consistent with a Time Magazine survey that found that 33% of women and men are only “pretty happy” in their marriage or partnership.

Why is good, good enough? Why do we accept mediocrity in our most important relationship? Maybe its because we’ve never been taught to expect more.
As kids during are formulating their dreams and expectations of their own future, their only education is about the physical aspects of sex. (Albeit, we do that too late too.) And, we focus almost exclusively on what NOT to do:

--Don't have sex

But, if you do...
--Don't have sex without a condom
--Don't get pregnant
--Don't have multiple partners
--Don't have sex under pressure
--Don't, Don't, and more Don'ts.

Why should talk about what TO do--how to have a healthy, intimate relationship; what to expect, and what to give to a partner; what it means to love and to be loved.

Is the conversation too uncomfortable? Too personal? Or, have you not figured it out for yourself? If we don't talk about it, we will continue to have generation after generation of adults who only focus on the physical, don’t prioritize the emotional, and then find themselves, in middle-age, unhappy and alone.

As the parents of three daughters, our greatest hope is that they find a mutually fulfilling partnership that empowers them to reach their potential. In order for us to model that for our kids, we had to learn about it for ourselves. In 2006, David and I saw an article in USA Today about a couples retreat at Miraval Resort in Tucson, Arizona. It was called "Partners, Pleasure and Passion." We were due for a vacation. What the heck, we decided to check it out.

Drs. Lana Holstein and David Taylor are a physician couple who specialize in sexuality and intimacy. They laid out a seven-dimensional model that includes the biologic--the nuts and bolts physical stuff. But, the model emphasized the equal importance of sensuality, desire, heart, intimacy, aesthetic and ecstatic. "Love isn’t about some technique, it’s being so close to someone that you can feel what they feel." Love between two people requires effort and work and ultimately means achieving a balance between these aspects in a partnership with another person. If you are using your imagination and wondering what it was like to be at Miraval, I can only reassure you that the most meaningful aspect of our weekend together was realizing how our strengths complement support each other as we strive to maximize and optimize who we are as individuals. We embraced the fact that love is not unconditional, and we shouldn’t assume it will be there forever, especially if complacency sets in and we don’t continue to meet each others needs.

The long-lasting benefit to Miraval is that we learned a framework that we share with our daughters—all three of them. Although awkward at times, we have open conversations about not settling for anything less than a partnership that includes intimate physical experience in addition to an emotional and spiritual pleasure, dignity, and self-respect. We talk about mutual acts of selflessness and what it really means to communicate, to trust, and to give. We want their antennas to be sensitive to signs of jealousy, dysfunctional and controlling behavior, as well as early and subtle signs of abuse. We want them to grow up knowing that love is very conditional.

Kids shouldn't learn about love and intimacy on TV or be limited to what they learn in 8th grade health class. They should learn about love from their parents. Learn to talk about it as a family. If you need help yourself, you can explore the meaning of love in an intense retreat setting or explore it more privately. Either way, make it a priority.

Make a toast to love in 2010. We have an opportunity to teach the next generation that good…is not good enough.

Happy New Year. Create Health.
Archelle

From Innovation to Intimidation

2009-12-17T22:02:00.000-06:00

I was not familiar with PrisonPlanet.com...until today. At noon, I received an email from a colleague who forwarded an article from this website with the headline, "Fox News Covers Mass Drugging of Society with Lithium."

First reaction: Oh s***.
Second reaction: WRONG!

On Sunday, I enjoyed reading the array of new innovations highlighted in the New York Times Sunday Magazine-2009 Year of Ideas. So, for my Fox segment this week, I highlighted three that were related to health:

1) Treating PTSD With Tetris
2) Thirdhand Smoke
3) Lithium In The Water Supply

On the lithium topic, I clearly stated that Japanese researchers had found that communities with higher trace amounts of lithium in the water had lower rates of suicide. I did not promote or endorse putting lithium in the water but simply said that the researchers would be exploring it further and that the findings were "interesting."

Here is a link to the segment so that you can see it for yourself.

While the headline was inaccurate, I brushed it off to media sensationalism and conservative passion especially when I realized the site was associated with Alex Jones, a radio journalist and documentary filmmaker who describes himself as being "on the front lines of the growing global information war from ground zero to the occult playgrounds of the power-mad elite."

But, a little later this afternoon, I received a call with no caller ID on my cell phone. I thought it was my sister. Instead it was a "reporter" who referenced the Fox segment and told me that I was "as despicable and disgusting as Adolf Hitler." My attempts to engage in a conversation were futile. Why did he call? To inform me that his organization was committed to using the next 3 days to discredit my reputation.

This is my first experience with being the target of a personal and hurtful attack. Readers comments on the site range from calling me "Frankenstine" and a "witch doctor" to "I shall brutally third hand rape her.."

There is only one way to respond...with facts. So, stay tuned.

Archelle

New View On Healthcare: Left Offensive Tackle

2009-12-07T11:23:00.000-06:00

The Blind Side taught me a few things about football, like the value of the left offensive tackle. I also learned a few things about myself when Sandra Bullock, playing Leigh Anne Tuohy, abruptly turned off the football game during Thanksgiving dinner and then scolded her husband for eating the string beans with his fingers. I saw myself on the screen. Leigh Anne's "don't get in my way" attitude hit close to home and her bling felt a bit familiar.

The movie touched my heart. For several days, my mind kept going back to various scenes and I wondered: what was real and what was Hollywood? What was this family really like? I spent several hours googling (is that word?) the Memphis-based family. Yes, Sandra Bullock and Tim McGraw have a striking resemblance to Sean and Leigh Anne Tuohy. More importantly, the story of Michael Oher and the opportunity that the Tuohy's gave him was real and an extraordinary example of giving. Leigh Anne's inspiration? In a video interview, she said "I just saw a need and tried to fill it."

Need is all around us, every single day. But sometimes, need appears in way and in a form that hits you (in this case, me) like a brick. It makes you stop dead in your tracks because acknowledging it forces you to challenge and re-think firmly held opinions and beliefs.

Last week's Fox segment was on COBRA insurance. The news centered around the fact that the nine month Federal subsidy available through the American Reinvestment and Recovery Act would be coming to an end for anyone who started receiving financial relief last March, the first month it was available. On average, the subsidy paid for $722 dollars (65%) of a $1,111 monthly premium.

My goal in the segment was to help people understand what their options are for health insurance and what to do next. As usual, I developed a graphic summarizing my key points:

Bullet #1: Stay insured at all costs.
Bullet #2: Shop online and compare costs.

As part of my prep, I went online to get health insurance quotes for my own family. I fully expected to find affordable options, but instead, I got a dose of reality. There were 46 plans to choose from. Here's a snapshot of the options for family coverage:

--Preferred One was the plan with the least expensive premium at $310.06 per month ($3720 per year) but with a $15,000 individual deductible. This means there would be an $18,720 out of pocket obligation before any benefit would be covered by the plan.

--Health Partners offered an option costing $396.47 per month ($4757.64 per year) with a $10,000 individual deductible. Comparing apples to apples, this would mean that we'd have to pay $14,757 out of pocket before any benefit coverage would kick in.

--Medica had a plan with a $700.97 monthly premium ($8411.64 per year) with a $5750 deductible. Annual outlay before benefit: $14,161.64

Oh, by the way. None of the plans offered maternity or mental health coverage. Bottom line: I couldn't find a plan that would offer benefits without a minimum annual expenditure of $14,000. This would be a hardship for households with 2 wage earners (annual median income: $76,752) let alone a family surviving on unemployment income of $15,996 per year.

Wake up call! I had spent 15 years reviewing, slicing and dicing medical cost data, but I wasn't engaged in setting premiums or deductibles or selling insurance. As a result, I was blind (and somewhat naive) regarding the actual cost to people. Nevertheless, during the televised segment on Wednesday morning, I stayed on message and firmly recommended that viewers "Stay insured at all costs." I went further and said, "Even if you can only afford a high deductible, catastrophic plan, at least this will help you avoid a financial catastrophe in the event of a medical emergency."

In my gut, my comments didn't feel quite right, but at the same time, I couldn't recommend being uninsured. This would have violated my firm belief that people must take personal responsibility for their health and health care.

During the online chat, I was flooded with questions: "Do I qualify?" "Can I get help?" "Do I meet the criteria?" "Does the subsidy cover my spouse's insurance or just mine?" And, then I got the question that hit me like a brick:

"Dr G, I can't even afford $300 a month. If I do, I can't buy groceries. So, which one should I pick: food or health insurance."

Need was staring me in the face, and the reality of the nation's health care crisis suddenly crystallized. No, I haven't had my head in the sand. Professionally, I was fully aware that there are 46 million uninsured, some of them because they simply can't afford it. However, until that moment, I clearly had been emotionally disconnected from this crisis.

I didn't buy health insurance for this viewer. However, this sobering moment made me think about how I could help families that are in this precarious situation. This year, instead of sending holiday gifts to friends and colleagues and writing token checks to big named charities, our family will work with local organizations to provide a credible health discount card program to 20 uninsured families so that they can get some help purchasing health supplies, prescriptions, and medical, dental, vision, and behavioral health services. While this is certainly not a substitute for health insurance, it may help bridge the gap.

I have always supported universal access to coverage, but with a strong conservative position that we should only expand access to insurance AFTER we control costs and restructure the entire system. I still believe that we need a sustainable approach to health reform, but affordable care for all Americans is an urgent need that we cannot ignore.

In retrospect, I have had a blind side to the needs of the uninsured; the movie inspired me to take go on offense and fill that need...one person at a time.

Create Health,
Archelle

Guidelines: Evidence-Based Judgment (Not Evidence-Based Medicine)

2009-12-01T10:18:00.000-06:00

I am trying to figure out why I am still upset (frustrated, angry, concerned) about the new mammmography guidelines issued 2 weeks ago. Am I that fearful of getting breast cancer? No. I am average risk. Am I afraid I won't get a mammogram when I want it? No. It's still covered by insurance and, to be honest, I'd pay for it out of pocket if I had to. Am I simply stubborn because I have Greek blood running through my veins? Well, maybe..but it's certainly not the underlying driving force.

So, what is it? It's about overstepping boundaries. Let me explain.

Conventional wisdom is that prevention saves money. Keep people healthy...improve quality of life...and decreases costs. Right? Not quite. A 2008 New England Journal of Medicine article that reviewed 599 preventive services and treatments found that 80% of them increase costs even after adjusting for the cost of care over 30 years. Why? Because preventive care, by design, is offered to people who wouldn't have developed the disease anyway, and the cost exceeds the savings. No, prevention is not the silver bullet that will cure the crisis fueled by increasing healthcare costs. However, prevention IS the right thing to do for society because it is an investment in the nation's health.

As long as guidelines remain just that, guidelines, they offer expert opinion and a framework that people can use to individualize their decisions. But who decides which preventive services will be covered and which ones won't? Which ones get paid for and which ones don't? Lets be realistic, for most Americans, coverage determines whether or not someone gets care.

For the 20% of preventive services that are safe, effective AND save money, like HIB immunization in toddlers, coverage decisions are straightforward and easy. However, for the vast majority of preventive services, the decision can't be reduced to a line on a spreadsheet. There is not a cost-benefit calculation. The absence of clear cut economic data means that the decision is based on the relative balance of clinical risks and benefits. However, balancing clinical risks and benefits feels strikingly similar to practicing medicine.

The breast cancer screening guidelines recommend that screening mammography be delayed until age 50 and stopped at age 75. However, there wasn't compelling data for these age cutoffs. There was no single study with a compelling p-value. While the Task Force apparently deliberated for 18 months and reviewed many different pieces of evidence, they ultimately had to base their decision on their own values, perspectives, and moral/ethical decision-making. Was this evidence-based medicine? No, it was evidence-based judgment. Balancing clinical risks and benefits for any health care issue is not the role of a government task force. It is a discussion that should be reserved for patients in collaboration with their physicians and other care providers.

HHS Secretary Sebelius was technically correct when she stated that the guidelines do not dictate policy. Today, they heavily influence policy. However, this may change. The Senate health reform bill includes provisions for a new $10 billion Prevention and Public Health Investment Fund that would be used to modernize the public health system, develop school based clinics, award grants for programs designed to create health communities, and expand access to evidence-based preventive services. All good stuff. However, buried in the bill is language stating that the HHS Secretary (in this case, Sebelius) is authorized to "modify coverage of any Medicare-covered preventive service to be consistent with U.S. Preventive Services Task Force (USPSTF) recommendations." Any preventive care services with a "D" (Not Recommended) recommendation would be at risk for non-coverage.

So, what services would that affect? Mammograms would still be covered. (Great!) They received "C" and "I" recommendations for the under 50 and over 75 populations, respectively. But, guys, listen up: Prostate screening would not be covered for men older than 75 since it has a "D" recommendation.

After contemplating this issue for a week, I realized that my response to the new breast cancer screening guidelines was not about advocating for women's health or men's health. Rather, it was about protecting the importance of personal decision-making. The government is about to overstep a boundary, and when that happens, my Greek blood starts to boil.

Health is personal. Protect it.
Archelle

Read the Guidelines NOT the Headlines

2009-11-22T21:26:00.000-06:00

"Whew!" This was my first thought when I saw the front page of USA Today on Tuesday that said, "Report: Mammograms May Not Be Needed Until Age 50."

I was relieved. This headline evaporated the guilt, and the private, unspoken fear I was feeling because I had procrastinated getting my routine mammogram. My last exam was in November 2006. So, even if I followed the most liberal guidelines, I was still a year overdue. I was planning to get it done at my 2008 annual physical, but my GYN's office didn't have an immediate opening. I walked out of the office without scheduling it...and, well, you know the rest. I just never got around to it even though I kept staring at the unchecked box on my To Do List that said "Schedule Mammogram!"

What would I say to my family if my negligence resulted in having an advanced breast cancer? While I knew I'd never forgive myself, I still didn't make it a priority. So, now I could stop rehearsing the Mea Culpas. I was home free for 3 more years.

I could have chosen to stop thinking about it until September 2012. That would make this blog post somewhat short. But, instead, I did what I usually do: I stopped reading the news reports and started reading the source documents posted on the U.S. Preventive Services Task Force (USPSTF) web site.

Here is what I learned:

The USPSTF used 8 studies to arrive at their recommendations. Data from these studies were pooled and modeled to arrive at the current results based on an algorithm designed by the USPSTF. Translation: The recommendations are based on a mathematical model--not a prospective controlled study.

The model showed that screening women between the ages of 50 and 69 years reduces breast cancer deaths by 17%. Starting screening at age 40 adds a 3 percentage point improvement so that breast cancer deaths are reduced by a total of 20%.

Is the 3% net improvement worth it? It depends..on the risks.

For every 1100 women aged 40-49 who have a mammogram, 10 will have a biopsy and 2 will be diagnosed with invasive breast cancer. So, there are 8 "unnecessary" biopsies to find 2 cancers. (Yield: 20%. Hmmm, not bad.) There were no studies quantifying the actual risk associated with these biopsies nor were there studies that measured risk of radiation exposure from mammography screening.

As I read the facts for myself, it appears that the benefits of mammography screening outweigh the risks for women between ages 40-49.

However, the USPSTF issued a "C" recommendation for screening women in this age group. This means that they recommend against routine screening for women in this age group but acknowledge that there may be considerations that support providing the service in an individual patient. What was their rationale? They focused on data that showed that 1904 mammograms have to be done to save 1 life when women between 40-49 are screened...versus only 1339 mammograms when women between 50-59 are screened.

1339 is worth it. But 1904 isn't. How did they arrive at this (arbitrary) standard? I am still scratching my head. I expect that this will be the question that is raised by the American Cancer Society and other specialty societies that are challenging the USPSTF recommendations.

So, what will I do? I will, as always, follow the Guidelines which state:

"Women 40-49: Do not screen routinely. Individualize decision to begin biennial screening according to the patient's context and values."

Unfortunately, the latter part of the guideline, recommending the individualization of care, wasn't clearly articulated by the Task Force's spokespeople or the media. They clearly missed an opportunity to focus on the importance of communication and shared decision-making between doctors and patients.

However, reading the Guidelines, not just the headlines, helped me fully understand the benefits and recognize the risks. I have individualized my decision. My mammogram is scheduled.

Create Health,
Archelle

From 411 to 911. Do We Need Something In Between?

2009-11-15T21:40:00.000-06:00

If your car suddenly develops a new hum, its a clear sign that you need to get it checked out by your mechanic.

If your computer is slow to boot and you see a fleeting (but dreaded) blue screen, you call the Geek Squad. Or, if you're really cool, you make an appointment for the Genius Bar at your local Mac Store.

But, what if you start hearing a click in your hip? What if your stomach keeps gurgling or if your eye starts twitching? When is it clearly time to see the doctor? The answer is not so straightforward.

As I look back over my 600+ interactions with on line chatters, 20% of the questions are from people simply trying to figure out when to appropriately access the medical system. How long should you wait? How bad does it have to be before calling and making an appointment? There were 2 questions this week that inspired me to write this week's blog:

1) "My husband has had alot of diarrhea since having a colonoscopy at least a month ago. Can that be normal?"

2) "I had an IUD inserted after having my 2nd child and have not had my period since. It's been about a year. Is that normal?"

No, neither is normal. Intuitively, both individuals already knew that. But, I realized that what they were really asking is: "Are these symptoms abnormal enough that I should see a doctor?"

When people have a health-related question or curiosity, the web offers quick, inexpensive access to information. At the other end of the spectrum, the criteria for calling 911 and seeking emergency care are fairly well-defined. In case you are wondering, the American College of Emergency Physician's criteria for seeking urgent or emergent care are:

-Difficulty breathing, shortness of breath
-Chest or upper abdominal pain or pressure
-Fainting, sudden dizziness, weakness,
-Changes in vision
-Confusion or changes in mental status
-Any sudden or severe pain
-Uncontrolled bleeding
-Severe or persistent vomiting or diarrhea
-Coughing or vomiting blood
-Suicidal feelings
-Difficulty speaking
-Unusual abdominal pain

However, there are countless symptoms that do not meet the threshold for going to the emergency room. What criteria should people use to seek non-urgent medical attention? After scouring the Web, I have convinced myself that there is not a list, a set of criteria, or guidelines to help people determine when to get care.

The CDC estimates there are 319 million office visits annually for new problems or symptoms--that's in addition to the 583 million visits for preventive care and chronic illness. Not surprisingly, cough is the most common reason for seeking care. With my doctor hat on, my reaction is "What a waste. Most episodes of cough are a viral upper respiratory infection and resolve without medical attention." But, with my consumer hat on, I realize that in the absence of clear and rationale guidance, people will simply develop their own framework for health care decision-making.

So, how do people judge when an abnormality is abnormal enough to deserve medical attention?

My observation is that people generally seek care when a symptom interferes with their lifestyle, work, or school or when a symptom is plainly visible or audible. Most of you reading this blog know that the presence or absence of physical discomfort or disfigurement caused by a symptom is not necessarily correlated to its level of health risk. However, for the majority of Americans, it is the only criteria that they can independently assess.

This helps explain the extraordinary number of visits for cough and sore throat as well as joint pain, headaches and skin rashes. It also sheds light on the reasons why one viewer ignored a small, painless lump on the tongue until it metastasized and why another with abnormal liver function tests didn't bother to follow up until he was jaundiced.

We need a better approach that makes it easy for people to know when to get care and when its reasonable and safe to let the body heal itself. The Web is not a practical solution since there are too many people who lack access to a computer, and too many who lack the education to properly interpret the information. Even among sophisticated health literate individuals, people who are worried about a symptom want the reassurance of a clinical expert.

So, why not develop "7-1-1"--a 24/7 national health information line that anyone can call to get immediate evidence-based guidance from a professional. When properly marketed to drive adoption, these "nurselines" have proven return on investment. Since 86% of visits include some type of diagnostic testing and 71% result in a prescription, avoiding unnecessary office visits also means avoiding the cascade of costly services that are inevitable when one steps into the medical system. Significant benefits also accrue from encouraging individuals to seek early care for symptoms that will inevitably progress into a serious condition.

In the case of the 2 online chatters, I let them know that their symptoms deserved further evaluation and encouraged them to follow up with the gastroenterologist who performed the colonoscopy and the OB/Gyn who inserted the IUD. However, in the case of the individual with a hip click, I let them know that a click is only worrisome if it becomes a clunk. (Not a joke!)

Create Health,
Archelle

"This Is It"

2009-11-08T17:57:00.000-06:00

I've been mesmerized by Michael Jackson since I was a kid, have secretly tried to replicate his dance moves, and have even done a Fox segment on his medical oddities. I was teary as I watched the funeral and rushed out to buy the Rolling Stones Magazine Special Commemorative Edition. So, you may not be surprised that I saw "This Is It" on its opening weekend since it offered a final chance for a front row seat to his concert.

Yes, I get am a star-gazer and a People Magazine subscriber. But, its an escape from how I usually view the world: through a business lens.

Most films are in production for the better part of a year, but "This Is It" was produced in 3 months. Columbia/Sony acquired the rights to the footage on August 10 for $60 million dollars. In September, at the MTV Music Awards, they committed to a releasing it on October 30. Due to public demand, it premiered 2 days earlier. And, the film is Oscar quality. With over $113 million in worldwide revenues, it is the highest grossing concert film of all time and is likely to be one of the highest grossing documentaries ever.

This multi-million dollar film was made in record time, but more importantly it was released to its audience on time. Expectations for its release were set in September and those commitments were met despite legal challenges and distribution issues. So, what does "This Is It" have to do with health care? It made me think about the H1N1 vaccine. What went wrong in the strategic planning, communication, and accountability (or lack thereof) that created the debacle that the CDC is facing as demand continues to exceed supply?

To answer my own question, I reviewed the CDC Press Briefings from April 23 through November 6. Here is a summary:

April: The H1N1 virus was recognized and isolated.
May: The CDC said they had initiated development of a vaccine.
July 29: The CDC press release stated that 159 million Americans are "high risk" for H1N1 and would be the priority groups for immunization.
August 21: Jay Butler, Director of CDC's H1N1 Vaccine Task Force stated "We're expecting somewhere between 45 million and 52 million doses of vaccine to be available by mid-October."
September 18: "We actually anticipate being able to start receiving orders for the vaccine by early October...The government has purchased 195 million doses."

So far so good. The government was on top of the pandemic. Americans took the warnings seriously and started washing their hands and sneezing into their elbows. Everything seemed to be on track so that about 30% of high risk individuals would be immunized by mid-October. The alarm over H1N1 may have even stimulated the economy a bit. J&J's stock (makers of Purell Hand Sanitizer) increased $5 per share between May and September.

But, as October arrived, a different story evolved.

The first time that the CDC Director, Tom Frieden, openly addressed delays in vaccine availability was on October 6. "As we anticipated, the first couple of weeks are going to be bumpy...But, I think what we're seeing now, is the tap beginning to flow... By the middle of this month, we're going to have tens of millions of doses available."

Okay, a bit optimistic, but give him a break. It was just the first week, and besides, they originally said the vaccine would be available mid-October.

On October 9: Anne Schuchat, Director for CDC's Immunization and Respiratory Diseases Center, said that the CDC is "ironing out the wrinkles...really, we think we're going to be in good shape in the weeks ahead." However, on October 16, when asked by a reporter about vaccine availability in upcoming weeks, she said "It's very difficult to predict exactly how many doses we'll have in the weeks ahead....As we have been saying over the months past, we can't with precision estimate exactly how much we'll have at any time."

Wait!! Didn't they say that there would be between 45 and 52 million doses available by mid-October? I understand being unable to have precision estimates, but they were off by 80%!

October 27: "This week, as of today, we have 22.4 million doses available for shipment out directly to providers and we're getting to the level where it will become significantly easier to find and receive vaccine."
October 29: "There are 24.8 million doses of the H1N1 vaccine that are available for the states to order....And over the next several weeks it should become more easily available.
November 3: "As of today, there are 31.8 million doses of flu vaccine available."
November 6: "Today, there are 38 million doses of H1N1 vaccine available."

During this week's online chat, someone asked me where they could get the vaccine in Minnesota. With the reports from the CDC suggesting that supply was increasing, I suggested the chatter go to flu.gov and the Minnesota Department of Health to find a local immunization site. She quickly came back on line to inform me that there are no immunization sites listed. She was correct. While the CDC reports that 459,000 doses have been shipped to Minnesota, the vaccine is not available to the public but has been primarily allocated to schools and health care facilities.

We are nearing mid-November and only 75% of the original expected supply of vaccine is available. That amounts to getting a C on a test after being given 1 additional month to prepare.

Okay, I'll stop with the problems and make some recommendations.

It's simply business basics:
1) Identify WHO is in charge and accountable. Is it HHS Secretary Sebelius or Jay Butler, or Anne Schuchat?
2) 'Fess up on all the issues--all of them.
3) Add experienced leadership to the CDC on supply chain management. Ultimately, it was poor manufacturer oversight that led to these issues.
4) USING DATA, establish conservative commitments (margin of error < 10%) on vaccine availability in communities.
5)Establish tighter national guidelines that assures there is consistent and equitable distribution to those at highest risk. Harness the resources of the state health departments.
6) Engage the media to help decrease the public panic about H1N1.
7) Apologize.

So, back to "This Is It." It was a great movie. But, what I saw from my front row seat is that Michael Jackson not only mastered his music...he WAS his music. He was a perfectionist and knew every note. Had he survived, his performances would have, once again, exceeded the world's expectations.

The movie offer 2 important reminders to all of us:
1) Underpromise and overdeliver.
2) Approach each commitment as if its your final performance.

Create Health,
Archelle