Health care in America: Going public, and private | The Economist →

...by the early 2020s the taxpayer will be footing the bill for half of America’s health spending, which will have risen to a staggering $5 trillion, equivalent to one-fifth of the country’s entire economic output.

I find this a bit unnerving...all parts of it.

I Had My DNA Picture Taken, With Varying Results | NY Times →

An interesting look at direct-to-consumer DNA testing. Interpretation by these companies can be quite variable:

In the case of Type 2 diabetes, inconsistencies on a semantic level masked similarities in the numbers. G.T.L. said my risk was “medium” at 10.3 percent, but 23andMe said my risk was “decreased” at 15.7 percent. In fact, both companies had calculated my odds to be roughly three-quarters of the average, but they used slightly different averages—and very different words—to interpret the numbers. In isolation, the first would have left me worried; the second, relieved.

Not to mention the limitations of the technology these companies employ (SNPs v whole genome sequencing). Craig Venter, who led one of the teams that first sequenced the human genome, is quoted in the article:

“Your results are not the least bit surprising,” he told me. “Anything short of sequencing is going to be short on accuracy — and even then, there’s almost no comprehensive data sets to compare to.”

Genomics will play a role in the future of medicine, but we’re not quite there yet.

The Post-Renaissance Man | slackadem →

In response to a recent Wired column entitled, Let’s Bring The Polymath—and the Dabblers—Back, Amol Utrankar argues in this post for ‘institutional collaboration: a culture that prizes sharing, communicating, and coordinating between different pillars of expertise.’ I don’t find this be an ‘either-or’ proposition necessarily. I think we will need people well-versed in the myriad of ‘tools’ for the modern world as well as organizational culture and structure that fosters collaboration.

Perhaps this is just a restatement of the polymath argument [1], but I find the most useful way to think about this subject is the notion of the ‘T-shaped specialist’. This is something first popularized by Tim Brown (of IDEO). In his words:

[T-shaped specialists] have a principal skill that describes the vertical leg of the T—they’re mechanical engineers or industrial designers. But they are so empathetic that they can branch out into other skills, such as anthropology, and do them as well. They are able to explore insights from many different perspectives and recognize patterns of behavior that point to a universal human need.

In my own conceptualization, the vertical leg of the T represents a domain where you are an expert. Not only are you well-versed in the tools of that domain and can use them with aplomb, but you also understand the theoretical side of the domain. The broad part of the T represents related domains where you may know some of the tools and some of the theory, but could not independently create or function proficiently in that domain.

This is the theory that shapes medical education—4 years of broad education in theory and practice with the tools of the trade followed by 3+ years in a specific domain. Unfortunately, medicine seems to fail at the ideal because we rarely revisit the broad part of the T. In such a world, Utrankar’s notion of ‘institutional collaboration’ is paramount (and this is ostensibly what we see with general practitioners consulting specialists).

However, to take on the challenges facing medicine today, we need more T-shaped doctors. We need experienced physicians to revisit the broad part of the T. This can take many forms. Dr Amesh Adalja recently wrote about his cross-training in infectious diseases and critical care. I recently worked in a clinic where an experienced general pediatrician spends a half day each week seeing patients with pediatric dermatologists so she could learn how they approach skin issues and take that knowledge back to her practice and her partners. You don’t have to look too far to see doctors with additional degrees in public health, business, public policy, education, etc. They are bridging two domains and enriching each with their knowledge. Some argue doctors should be learning how to code in order to bridge the gap between medicine and information technology [2].

The challenge of medical education—specifically graduate medical education and continuing medical education—is finding a balance between specialty knowledge and cross-domain education. And the challenge for hospitals, private practices, and other health care organizations is how to cultivate T-shaped specialists amongst their own ranks.

  1. I think there is more than a semantic difference between a ‘polymath’ and a ‘T-shaped specialist’. I conceptualize a polymath as someone with multiple deep expertises, cultivated over a long time with dedication to each of those fields. A T-shaped’ specialist, on the other hand, has one true expertise with some training/education in multiple other fields.  ↩

  2. Some argue that since you can’t become an expert in one of these other domains, why learn anything about them at all? The Digital Doctor podcast episode I’ve linked to addresses this nicely. It is not about being an expert in multiple disparate domains (which is what I would consider a ‘polymath’ to be), but being well-versed enough in those domains to engage others in meaningful collaboration (and—almost more importantly—to know when to engage others in those domains).  ↩

Setting Boundaries on Smartphone Use in Hospitals | The Doctor's Tablet →

I completely understand why an institution would create a 'smartphone use' policy. But at the same time, how little do you trust the people working for you? How broken is your culture of professionalism that people now have to announce why they are using their smartphone? Do you also make them ask permission to go to the bathroom?

First and foremost, attendings and senior residents must set the example. Then, these same supervisors need to keep a casual eye out for interns and med students misusing devices. If that were to happen (which is much less likely if the attendings and senior residents create a culture of professionalism), then pull the junior member of the team aside and address the issue.

I don't think this requires a separate policy and I don't think the creation of such a policy is something to celebrate.

Teaching Hospitals Examine New Ways to Convey Research Risks, Benefits to Patients | AAMC Reporter →

I find it encouraging to see researchers looking for innovative ways to improve the informed consent process. However, given the United States’ low health literacy—well, low literacy in general—I find true informed consent to be an elusive ideal. I think it would be prudent for Institutional Review Boards, especially non-medical community members, to make this an area of interest when reviewing proposals.

I believe the biggest challenge is not necessarily the complicated biomedical science that may be involved, but the probabilistic nature of research. When a research question has true equipoise, we really don’t know what will happen. That is a difficult concept to explain and even harder one to wrap your head around when facing an illness.

Using Good Design To Eliminate Medical Errors | FastCo Design →

This article exemplifies how I think design thinking combined with patient safety/quality improvement tools will change health care. However, the road will not be easy:

The lead designer of DOME [‘designing out medical error’] was Jonathan West…he initially thought there’d be one or two glaring areas for improvement that could be tackled in a couple big designs. He quickly realized, though, while shadowing doctors and nurses at the hospitals of the Imperial College of London, that what makes the problem so persistent is that it’s extremely complex.

“It’s not like an airplane falling out of sky or a nuclear power plant exploding–there’s no one big thing,” West says. “The process is different for each patient, so the process can go wrong in unique ways, which makes it very hard to tackle in terms of design.”

Unfortunately, not only is the task difficult, but current financial incentives are not aligned for investment in such initiatives. Improving design in health care will require upfront investment whose return is difficult to measure [1] and ultimately decreases revenues [2]. But, we know it is best for the patient, the ultimate guiding edict in medicine.

We need physicians and other health care providers trained in design thinking to move patient safety/quality improvement efforts forward.

  1. Note which outcomes they cited in measuring the success of the CareCentre: ‘Compared to wards with standard equipment, those with the CareCentre had better hand hygiene, fresh glove and apron use, and old glove and apron disposal.’ These are all process measures; there is no indication of whether or not medical errors were reduced or if more patients got better.  ↩

  2. Remember, under our current fee-for-service system, most hospitals get paid more for doing things. Preventing errors means there is less to do.  ↩

Mission Impossible V - The MOC Exam | Dr Wes →

Taking exams to become a physician—all the way from the MCAT, to the Step exams, and specialty boards—seems to require an inordinate amount of security. When taking the Step exams (which allow for 6 or 7 breaks), you have to signout, sign back in, rescan your fingerprint, and pull out your pockets each time you take a break [1]. But who is going to stand up to the boards and challenge these ridiculous procedures? They don’t care; they never go through this stuff.

  1. My best test-taking tip—don’t wear anything with pockets.  ↩

✚ Tech Rounds - Twitter tools

For me, Twitter has become in invaluable tool in keeping up-to-date with what is going on in the health care world and connecting with others. Twitter’s growth in its early days relied heavily on third party clients. Until some recent changes, Twitter cultivated a rich ecosystem of third party apps. Thus, there are lots of Twitter tools to choose from. However, I essentially rely on only a few choice apps for 99% of my Twitter use. Below, I talk about each—divided by platform—and how I use them.

Computer

Tweetbot

Most of the time I’m at my computer, I have Tweetbot open in the background. It is a simple, but powerful app. Though you can open multiple panes or even windows to view various timelines, I generally leave my main timeline open. Tweetbot will stream your main timeline, so I can keep an eye on tweets while doing other things. I have also linked my Pinboard account so that when I see a link I want to look at later, I can easily send it to Pinboard.

Tweetdeck

The other main Twitter tool I use while at my computer is Tweetdeck. I primarily use Tweetdeck for two purposes—viewing multiple timelines and participating in tweetchats. Unlike Tweetbot, I do not keep Tweetdeck open all the time.

Though you can open multiple panes in Tweetbot, Tweetdeck serves this purpose better because it was designed for such activity. With Tweetdeck, I’ve created a layout with my main timeline, several hashtag searches, my lists, and a few other miscellaneous timelines. So, when I want to see what’s going on in multiple places, I can simply open up Tweetdeck and check in.

Tweetdeck is also ideal for participating in tweetchats. Simply create a column in Tweetdeck with a saved search for the hashtag used for the tweetchat. Tweetdeck will stream the tweets for that hashtag (as long as you’re at the ‘top’ of that column). I also place a column with my @mentions next to the tweetchat hashtag column so that I can keep an eye on people who are responding to me.

Twitter

Twitter does make their own client. I have it on my computer, but I only open it to remind myself what a terrible user-experience is like.

A note on managing multiple accounts—Both Tweetbot and Tweetdeck allow you to work from multiple Twitter accounts. Tweetbot is ‘modal’ in terms of account management—you can only work from one account at a time, though it is easy to switch between accounts. Tweetdeck allows you to easily intertwine multiple accounts and send a single tweet from various accounts. Each approach has its pros and cons. If you’re prone to accidentally tweeting from the wrong account and it is important for you NOT to tweet from the wrong account, then Tweetbot’s approach is ‘safer’. Tweetdeck is much less cumbersome to switch between accounts, with the obvious tradeoff that it is much easier to tweet from the wrong account.

Mobile (iOS)

Tweetbot 3

Tweetbot exists on both the Mac and iPhone. Like the Mac version, Tweetbot 3 (their latest iteration) is my go to Twitter client on my iPhone. It is almost unquestionably the best Twitter client not only on the iPhone but on any platform—iOS, Android, Mac, PC. It works similarly to the Mac version, so it is easy to switch between the two. Just get it, you won’t be disappointed [1].

When setting up Tweetbot, don’t forget to go to the settings and then into the account specific settings. Here, you can hook up your Pinboard account as the ‘Read Later’ service. This will allow you to send tweets and links directly to Pinboard.

Twitterrific

The only other Twitter client I have installed on my iPhone is Twitterrific. I love the design of Twitterrific, especially the dark theme. Unfortunately, Twitterrific has an Achilles’ heel for me—it doesn’t stream tweets. While Tweetbot will continually add new tweets if you’re at the top of your timeline, Twitterrific requires the ‘pull to refresh’ gesture to check for new tweets. Though I don’t often sit and just watch my timeline on my iPhone, when I do I don’t want to have to constantly be tugging at the screen to get new tweets. Aside from this rather significant shortcoming, Twitterrific competes for best iPhone Twitter client. It has a few unique features—most notably a unified timeline—that are worth checking out.

HootSuite and Buffer

Both HootSuite and Buffer seem to be very popular. I don’t use either of these services. I think they add an extra, unnecessary layer and I’ve found I can accomplish anything they provide using other services [2]. Additionally, if you want or need any of the paid features with either service, they are exorbitantly expensive.

Those are the basic tools I use for interacting with Twitter. I have tried some others, but these are far and away the best. If you have any suggestions for a Twitter client I should try or a topic for Tech Rounds, please let me know.

  1. Tapbots updated Tweetbot on the iPhone to match the redesign that came with iOS 7. Thus, Tweetbot 3 is an iPhone only app; previous versions of Tweetbot were universal apps (e.g.—both iPhone and iPad). I assume Tapbots is furiously working on an iPad version and will release it as soon as it’s ready. Until that time, the old Tweetbot is probably the best iPad Twitter client. It just looks a bit out of place with iOS7.  ↩

  2. If people are interested in how I accomplish what HootSuite and Buffer do via alternative means, just leave a brief note. I will respond directly or do a post about it. I didn’t go into it here because I think it would be exceedingly boring.  ↩

Shopping for health insurance is hard - Understanding it is even harder | Washington Post →

The article quotes a study in Health Affairs:

Low health literacy could reduce the gains for consumers, particularly…if the consumers who do enroll face unexpected out-of-pocket expenses.

I do not have low health literacy and I find it difficult to understand health insurance plans. In a class recently, we were given various Medicare patient scenarios and then challenged to use online Medicare calculators to figure out which coverage would be best. Everyone—about 25 fourth year med students—found this to be challenging at best.

I think we are moving towards a tipping point where more direct financial relationships between physicians and patients will be necessary.

How Google Glass will save your life one day | iMedical Apps →

Nothing in this article led me to believe Google Glass will save my life one day [1]. Iltifat Husain MD gives a brief run-down of his experience with Google Glass over the past few weeks, but fails to provide any concrete examples of where it made a difference in his practice of medicine.

His major point is that ‘hands-free is a big deal’:

In medicine, we use our hands all the time, whether we are examining a patient, administering medications, or doing a procedure. Glass enables you to do all three of these things while keeping your hands free.

And then on the next page, he also writes:

It’s crucial to know how distracted you look when using Glass. When you’re using the audio and touch prompts, it gives a look of you being in your own world…I would argue the best patient edict is to hang Glass around your neck when talking to a patient.

Being able to do something hands-free doesn’t mean you’re then able to do multiple things at once. Practicing medicine requires attention, both when talking to patients and doing procedures. I don’t think it is prudent to divide one’s attention between placing a central line and a screen in the corner of your field of vision. I think most patients would prefer the doctor to be focused on one task when they’re shoving a giant needle into their neck. And if you’re constantly hanging Glass around your neck to avoid Google Glass attribution error, doesn’t that hinder the immediacy of information, one of the key features?

Additionally, the hands-free feature of Google Glass seems to be quite poor. A cardiothoracic surgeon at UCSF who trialed Google Glass for three months found voice commands with Glass to be so problematic that he eventually put a separate technician in the operating room to ‘keep things running smoothly.’ Though this will undoubtedly improve with time, voice commands will also have to deal with medical jargon and may prove too unintuitive for much beyond basic navigation.

Google Glass likely will find a place in many physicians’ practices, but I think those will be specific use cases. I also think it is going to be several years before anyone develops anything of particular use to warrant widespread adoption among physicians.

  1. This article title is such link bait, I initially resisted posting about it. Google Glass will never save anyone’s life; possibly, somebody using Google Glass may save your life…someday…  ↩

Rag3 Aga1nst the Fax Mach1ne | med*t3ch →

When I see a fax machine, I can’t help but wonder: Are physicians not ashamed that paper charts, nine-to-fivers, and ancient technology stand in the way of instant decision-making?…Are they not embarrassed that barriers to information sharing put patients at risk for the morbidity associated with repeat diagnostics? Do they not feel foolish when they perform the same tests that were done recently at an outside hospital?

Exactly. We should all feel ashamed, embarrassed, and foolish.

One Medical Group Scholarship →

One Medical Group—a forward thinking primary care practice—is offering a $10,000 scholarship for 3rd year med students interested in primary care.

If you haven’t heard of One Medical Group, you should really check them out (and not just for the scholarship opportunity). They are among a handful of practices trying to reshape the face of primary care. The NY Times had an excellent article about them a couple years ago.

The application opens Jan 10 and closes Mar 14. This is a great opportunity for some ‘free money’!

"We Need to Talk About TED" | Benjamin Bratton →

Excellent critique of the increasingly popular ‘TED talk’ format. He writes [emphasis mine]:

Let me tell you a story. I was at a presentation that a friend, an astrophysicist, gave to a potential donor. I thought the presentation was lucid and compelling…After the talk the sponsor said to him, “you know what, I’m gonna pass because I just don’t feel inspired… you should be more like Malcolm Gladwell.”

At this point I kind of lost it. Can you imagine?

Think about it: an actual scientist who produces actual knowledge should be more like a journalist who recycles fake insights! This is beyond popularization. This is taking something with value and substance and coring it out so that it can be swallowed without chewing.

The whole post really is great and worth the read. I have had similar thoughts and wrote about one deficiency of the format after I attended TEMED in 2012. I have reproduced that post below.

The missing element of TEDMED - critical discussion (Apr 2012)

TEDMED is a conference that bills itself as, “… a safe place where people with very different ideas can come together to talk, to learn and to celebrate the amazing world we live in.” Speakers and performers—all leading experts in their respective fields—come together to share their ideas about the future of medicine and technology. Presentations are only limited by the speaker’s imagination and the 18 minute time limit. TEDMED’s openness to imaginative ways of thinking about medicine, health care, biomedical research, and well-being produces 4 days of mind-bending talks and performances.

Despite TEDMED’s decidedly forward-thinking subject matter and format, one critical element is missing from the formal structure of the conference–critical discussion of presentations. Almost every single “traditional” medical conference features talks followed by a brief period for public discussion with the presenter about their ideas. TEDMED is devoid of such public critical discussion. Instead, discussions are relegated to the attendees analyzing presentations amongst themselves during breaks in the Social Hub (TEDMED’s sponsor venue) or short exchanges on Twitter or blog posts weeks after the event when the videos are posted online.

Jay Walker—TEDMED’s chairman and emcee for the event—provides some faux analysis after each speaker in the form of a brief summary and a few crowd-sourced questions. However, this serves more to simply reinforce the speaker’s thesis and stroke their ego than critically analyze what he or she said.

The lack of critical analysis consequently allows some speakers to freely conflate marginally related ideas and invoke anecdotal evidence in support of their hyperbolic assertions. It also misses a tremendous opportunity. TEDMED is much more than the small lineup of speakers; its attendees (TEDMED calls them “delegates”) are also innovators and broad-thinkers at the cutting edge of medicine and health care. Why not allow them to engage with the speakers in a public forum for all to hear? While at TEDMED this year, I had some of the most engaging discussions with other attendees and a hundred such discussions occurred at each break. It is a shame a piece of these discussions are not captured for the public.

As often as I am able, I like to suggest a solution whenever I see a problem. I think the solution here is to add a component to the TEDMED Connect app whereby attendees can verbally ask questions and engage with the speakers in a brief discussion session after each talk. During the talk, attendees in the room can jump onto the TEDMED Connect app and touch a button indicating they would like to ask a question at the end of the presentation. At the conclusion of the speaker’s talk, persons indicating they had a question would be recognized one by one. Their smartphone (via the TEDMED Connect app) would become a microphone so that their question could be broadcast over the speakers in the auditorium and the video feed. They would stand up, ask their question into the microphone of their smartphone and engage with the speaker, then sit down and let the next person participate. Time is always an issue, so this could be limited to 3 people or so.

Regardless of its implementation, TEDMED needs to allow for attendees to engage with the presenters after each talk. Critical analysis is the chief means of raising the discourse at conferences. For TEDMED to cement its place as the preeminent event for discussing the biggest ideas in medicine and health care, its discourse could certainly use a boost.

drchrono Enhances iPad EHR: API, Apps | InformationWeek →

drchrono started with a ‘mobile first strategy’ [1] and now seems to be leading the pack with API access. If I were setting up my own practice, I would be looking veeeerrry closely at drchrono for my EMR [2].

  1. Arguably, if you’re making a digital product, you should always begin by designing for mobile devices first. Not only do most EMR companies not adopt a mobile first strategy, most don’t have any sort of mobile strategy. drchrono has really been a leader here.  ↩

  2. Sadly, I’m doomed to a life of EMRs being chosen for me as I would like for research to be a part of my career, thus I will be relegated to ivory towers of academic medical centers.  ↩

Counterpoint: Why Graduate Medical Education will be fine | Boring EM →

A really great piece by Teresa Chan MD in response to a post on KevinMD entitled, ‘Why graduate medical education is failing,’ by J. Russell Strader MD. I highly suggest reading both.

Dr Chan writes in her conclusion:

This whole Counterpoint has boiled down to one thing: it’s time we got more critical about the blogosphere. We need to stop posting unsupported and non-evidence based conjecture without so much as a shred of corroborating evidence…A blog is not a peer reviewed journal, but it should take the evidence into account when drawing conclusions.

I agree with this sentiment (and think Dr Strader’s post was pretty egregious in its unsupported assertions) but I also think we should be cautious about restricting opinion in any fashion. My fear is that people may hesitate to write a piece or express an opinion because they are afraid evidence exists they may not be familiar with [1]. Blogs and social media function better with the exchange of ideas. When a bad idea is shared, there is an opportunity to do exactly what Dr Chan has done—respond. I have recommended reading both posts because I think both are enlightening representations; I think we’re better off with both posts [2].

  1. This is actually how I feel about resident work hours. I know a large body of evidence exists, but I have not done any research work in that area so I’m not very familiar with it. It would take me some time to find the ‘best’ papers and accurately refer to their conclusions. Thus, I refrain from writing strong opinions about the subject.  ↩

  2. Arguably, Dr Chan’s post would be shorter and more readable if she cut out the vitriol and focused on making a counterpoint.  ↩

Administrative data for HAI surveillance: fuhgeddaboudit! | Controversies in Hospital Infection Prevention →

Good discussion of some of the cons of working with administrative or billing data for research. While sensitivity is quite variable for using stuff like ICD–9 codes to define cases, specificity is generally very high. This can be a good thing so, let’s not throw the baby out with the bathwater. There are instances when these parameters are acceptable.

Most of the research I’ve done has involved administrative data [1]. In the first paper I published [2], I looked at trends in antibiotic use for Staph aureus infections over the past 10 years for hospitalized children. I relied on administrative data which gave me the benefit of using data from children’s hospitals all over the country and allowed me to look at over 60,000 cases going back to 1999. Because ICD–9 coding is not perfect, sure there were cases I missed. But, I can be almost certain (given the generally high specificity) that all 60,000+ cases I looked at were really due to Staph infections [3]. This same study could easily have been conducted at a single institution and would have taken 5 times as long and not had nearly the same power. Or, I could have formed a multi-institution consortium (easily a years worth of work alone) and spent tens of thousands of dollars conducting this same study at multiple sites over multiple years using confirmed microbiology and pharmacology data. (I think I would have come to the same conclusion.)

The conclusion of the blog post by Dr Edmond states:

Perhaps the forthcoming ICD–10 will help, but the fundamental issue of only reviewing physician notes will remain. More sophisticated methods utilizing computerized algorithms for analyzing electronic medical records for case detection will probably be the ultimate solution.

ICD–10 may help, but really the ultimate solution is making the microbiology data (and other laboratory data) more accessible. The Achilles’ heel of using billing data for infectious diseases research is that micro lab data is not contained in administrative datasets [4]. This should improve with wider adoption of EMR systems, as well as natural language processing systems that will allow us to easily parse notes.

Bottom line—many tools exist for clinical research. None is perfect. It’s important to know both the pros and cons of your tools so you can use them appropriately.

  1. Guess what my opinion on administrative data for research purposes is?  ↩

  2. Shameless plug!!! Read my research!! (Don’t really, unless your in peds…and probably only if you’re in peds ID.)  ↩

  3. Admittedly, there is lots of nuance I’m skipping over here. I suggest reading the discussion section of the paper I’ve linked to for some more insight into the limitations of using billing data (and the limitations of that paper specifically).  ↩

  4. What IS in administrative or billing datasets you ask? The general rule of thumb is anything you can be billed for. So, you can see that someone had a blood culture (because they get charged for that) but you don’t have the results from that blood culture. (Depending on the dataset, you may not even know it is a blood culture, only that something was cultured from somewhere on the patient…)  ↩

Finding your role model | American Resident Project →

Role models come in various flavors. Some are experienced, senior professionals who take on trainees as part of their responsibilities. Others are more junior and the relationship feels more like a lateral partnership than vertical mentorship. Role models can even be people in a vastly different field or someone you don’t know personally, but would like to emulate [1]. I think it’s important to not only have a role model, but ideally one from each of these categories. I find they serve different roles and having multiple people you can turn to means you get multiple perspectives. When dealing with a difficult problem, typically no one answer is absolutely right. You have to choose among equally ill-fitting options and having various perspectives to sort through such options helps you get a 360 view.

  1. Hero worship is a real danger with role models you don’t know personally. Remember, nobody is perfect; the sides of others lives we see (especially for well-known people) are carefully curated to give the appearance that everything is effortless and without problems.  ↩

✚ The false epidemic of chronic illness among young, rich Americans

I read a recent article in The Atlantic entitled, ‘Living Sick and Dying Young in Rich America,’ with great interest [1]. In this article, Leah Sottile writes about the chronic illness her young family faces—

I thought this would be the time when we’d be preparing for the rest of our lives: earning money, going on fun vacations, having families, building our careers. And we are, but at the same time, we’re doing it while we’re trying to manage pain symptoms, chase down prescriptions, and secure stable health insurance…

I wondered if this was normal. Do we know so many people who are dealing with pain because people are just getting sicker in general?…It turns out that chronic conditions like what Joe and my friends are dealing with are one of America’s biggest health emergencies.

I read on with incredulity. I have been in medical school 4 years. I have studied and followed public health for the past 9 years. I had no idea America was facing an epidemic of chronic illness among 30-somethings. Why haven’t I heard about this? Why haven’t I been learning about it in my classes or on the wards?

After reading through the source material referenced by The Atlantic, I have a hard time coming to the same conclusions as this article.

The article begins with the author writing about her husband’s struggle with ankylosing spondylitis (an autoimmune disease). Then goes on to talk about a close friend dealing with lupus (another autoimmune disease) and fibromyalgia.

In our close group of friends—who range from 25 to 35 years old—we know people with everything from tumors to chronic pain.

Though this last statement is quite vague, it seems from the initial few paragraphs there is an epidemic of autoimmune disease among young Americans. (The epidemiology of autoimmune diseases is quite dynamic. While the incidence of some have increased, others have decreased.) However, the article only uses the word ‘autoimmune’ four times; instead, the argument is framed in terms of ‘chronic’ diseases (mentioned 10 times).

In support of this epidemic of chronically ill young adults, the article links to a 2013 report by the National Research Council and Institute of Medicine entitled, ‘Shorter Lives, Poorer Health,’ and states—

But it’s not just that Americans are getting sicker—it’s that young Americans are getting sicker…“The panel was struck by the gravity of its findings,” it reads. “For many years, Americans have been dying at younger ages than people in almost all other high income countries.”

Though the quoted sections above are accurate, the conclusion that ‘young Americans are getting sicker’ is not (at least not in terms of chronic diseases). In the summary for the NRC/IOM report, the authors list nine domains where America fares worse than their peer countries:

  1. Adverse birth outcomes
  2. Injuries and homicides
  3. Adolescent pregnancy and sexually transmitted infections
  4. HIV and AIDS
  5. Drug-related mortality
  6. Obesity and diabetes
  7. Heart disease
  8. Chronic lung disease
  9. Disability (noting this specifically amongst older Americans)

In reference to this list, the report notes—

The first half of the above list occurs disproportionately among young Americans. Deaths that occur before age 50 are responsible for about two-thirds of the difference in life expectancy between males in the US and peer countries, and about one-third of the difference for females.

The first half of the list (items 1 - 5) do not encompass any chronic disease [2]. The causes of America’s worse outcomes in these domains are most closely linked to poverty, risky behaviors, and poor access to health care. The report goes on to note that the poor health status of Americans at age 50 is caused by ‘chronic diseases that arise from risk factors (e.g.—smoking, obesity, diabetes) that are often established earlier in life.’ They do not link such poor health status of 50 year-olds in the US to a mysterious explosion of autoimmunce diseases among 20 - 30 year-olds.

The Atlantic article also points to a report from the Univ of Washington’s Institute for Health Metrics and Evaluation entitled, ‘The State of US Health: Innovations, insights, and recommendations from the Global Burden of Disease Study,’ and says—

In fact, a recent report…says that “in some U.S. counties… life expectancies are on par with countries in North Africa and Southeast Asia.”

The report indeed states this, but the report does not support the implied assertion that these lower life expectancies are from an epidemic of autoimmune diseases among young Americans. The IHME writes—

In the US, we found that life expectancy increased, but the number of years Americans spend living with disability also increased. Ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease (COPD), and road injury were responsible for the greatest number of years of life lost in America in 2010. Musculoskeletal, mental, and behavioral disorders, such as low back and neck pain, depression, and anxiety, were the leading causes of years lived with disability. Looking at risk factors for disease and injury, GBD researchers found that dietary risks, such as eating too little fruit, nuts, and seeds and too much salt, were the largest contributors to disease burden, followed by smoking, high body mass index, high blood pressure, high fasting plasma glucose (high blood sugar), insufficient exercise, and alcohol use.

The Atlantic piece also refers to testimony by Steven Woolf MD MPH, director of the Center on Society and Health at Virginia Commonwealth University, in front of the US Senate. They link to a YouTube video from Senator Bernie Sanders as a reference; this video does not contain any of the testimony attributed to Dr Woolf in the article [3]. In fact, during his brief appearance in the video, Dr Woolf mostly discusses the link between poverty and poor health in the US.

Living with a chronic disease—autoimmune or otherwise—at any age is difficult. Doing so at age 30 would undoubtedly be life-changing. I do not wish to minimize any person’s experience dealing with a chronic disease. I do wish for people to accurately understand the nature and distribution of disease so that we can have a meaningful dialog about improving health care. Unfortunately, I believe this article in The Atlantic misrepresents disease in America and detracts from such dialog. Many people worked very hard to produce this research; it is important to honor their work.

The subtitle for this article is, ‘Chronic illness is the new first-world problem.’ Chronic illness has always primarily been a problem in developed countries. In fact, the real news is that chronic illnesses are increasingly a problem in poor counties. The whole world is struggling with chronic illness, not just young, rich Americans.

  1. This article appears in The Atlantic’s ‘Health 2014: Bright spots in a troubled system’ series.  ↩

  2. Arguably, HIV/AIDS (due to advances in anti-retroviral treatment) and drug-related mortality (as outcomes due to chronic mental illness) are now chronic illnesses.  ↩

  3. The YouTube video does contain some testimony from Dr Woolf, starting at the 2:05 mark. However, it doesn’t contain the specific testimony quoted in The Atlantic.  ↩