January 31, 2015

Primary Care Is So Over

There are close to a quarter million primary care physicians in the U.S., more than any other individual specialty, and about half the total number of all specialists combined. Yet, somehow, primary care seems to lack the power and social influence necessary to chart its own professional course. As the availability and granularity of specialist physicians increased, the value proposition of a generalist primary care doctor seems to have become unclear to those who pay for medical services and to physicians as well. As a result, primary care medicine was forced to price itself lower than specialized medicine, and now it is being forced to compete with a variety of other business models. Primary care seems to be experiencing an identity crisis, unable to decide if it is the cornerstone of medicine, or an antiquated service whose time has passed.

What is primary care?

The primary care name itself can be understood in two very different ways, depending on how you translate the word primary. It could be seen as the first step one needs to take when engaging with the medical system, a step followed by secondary care, tertiary care, etc. This is the gatekeeping view, where primary care doctors apply their knowledge to direct patients to appropriate specialized resources, if necessary. Since there could be multiple specialized resources, and since medicine is very complex, the gatekeeper doctor is also tasked with follow up, coordination and general supervision. In the business world, this job is known as project management, and it is usually filled by workers that need not be expert at anything other than management of tasks and resources.

Another way to look at primary care is to assert that it is the central and predominant type of medical care, or the way most medical care is provided. In this model, the primary care physician is expected to treat and resolve all but the most unusual medical problems, which may from time to time require a consult with a specialized resource. A consult is not the same as a transfer of care. This type of practice requires that the primary care physician has more knowledge and more understanding of the patient than all transient specialists put together. And this type of super doctor cannot be either underpaid or easily replaced. Unfortunately, short of some old timers here and there, nobody practices primary care quite this way anymore.

There are many reasons why medicine developed into an essentially fragmented model of care. The often touted explosion in medical knowledge, beyond what one human can accumulate and apply, is probably not as instrumental here as money and power seem to be. There are only a handful of diseases that make life miserable for most people, and eventually kill us all, and data shows that most medical resources are spent on a tiny percentage of people at any given time. It is difficult to reconcile these realities with the assertion that we need hundreds of thousands of highly specialized resources, because no one doctor can master the intricacies of a few run of the mill diseases occurring over and over across the board, and seriously affecting only a minority of patients. This, by the way, should not be confused with the obvious need for having a great variety of specialized research in academic and industry settings.

Whatever else it might be, primary care is a $100 billion per year industry in complete disarray. In addition to its own revenues, primary care as it stands today, heavily influences the flow of revenues in all other health care sectors. This should explain rather nicely why so many businesses are trying to be part of it, trying to reform it, reinvent it, flip it, control it, or just replace it. What practically all these innovations have in common is a tacit agreement to adopt the lighter definition of what primary care consists of, for the very simple reason of reducing barriers to entry into this potentially lucrative market.

Keeping People Healthy

In today’s complex environment, individuals cannot be trusted to care for themselves or their children, and rightfully so. The survival and prosperity of our society is predicated on passive consumption of massive quantities of goods and services. Our electronic way of life is designed based on the timeless axiom of “don’t make me think”, and an extra click of a button is considered undue burden on average consumers. We are expected to ingest billions of Big Macs to keep the economy chugging, and go through trillions of disposable trinkets sold on the Internet to keep WWIII from erupting. Even getting the news every morning has been replaced with news “feeds” to save you the long walk down the driveway to pick up the old newspaper. And turning pages, even on the Internet, is too much of an imposition. What makes us excellent consumers is also rendering us unfit to be trusted with our own health.

In this age of patient empowerment and freedom from paternalistic physicians, it seems that primary care doctors are being put in charge of keeping us healthy. It only seems that way though, because nobody needs a doctor’s education and expertise, not to mention expense, to figure out what every good grandma, and every single one of us, knows already. Besides, going to see a doctor does not fit with our tried and true, instantly gratifying, passive consumption paradigm. In our new way of so called life, primary care becomes an electronic assistant that uses, and is used by, every consumer, every day. Note that the modern term “primary care provider” is specifically geared to this low level function. Nobody uses the term cardiology provider, or surgery provider, or even pediatrics provider, to refer to a medical doctor. Primary care is different.
  • Primary care monitors your food intake and level of exercise, reminding you to eat your veggies (or no dessert) and take your constitutional regularly
  • Primary care reminds you, or schedules for you, health screenings and preventive care services as recommended by your government
  • Primary care monitors your vital signs and lets you know if normal parameters are exceeded
  • Primary care answers your questions if you feel under the weather, or just concerned that you might be
  • Primary care treats minor illness and injuries, such as mosquito bites and nail fungus
  • Primary care is available 24x7 from the comfort of your iPhone, or in extreme cases next to the bakery counter at your favorite discount store
  • Primary care is provided by Siri and augmented by certified technicians with impeccable customer service credentials
If you have a sudden urge to kick me in the shins right now, remember that primary care is not your profession. You are credentialed in Family Medicine, Internal Medicine or Pediatric Medicine, keyword here being Medicine. Yes, you may be providing some of these services for some of your patients, mostly for free, but is this really what you want to do all day, every day? Yes, having people come see you when they are healthy, better equips you to care for them when they are sick, but this seems a luxury few can afford today. The new primary care has as much to do with practicing medicine, as fixing traffic tickets has to do with practicing law. It is a piece of your old practice that has been successfully carved out by competing businesses that can and will be providing these, and many more, services to your patients. And if you’re not careful, specialists will take whatever is left on your plate.

Healing the Sick

When primary care was defined by Barbara Starfield as high quality, compassionate, comprehensive general medicine, it was an honor to be called a primary care physician. Today, the term is becoming essentially oxymoronic. Physicians, contemplating the plucking of low hanging fruit from their scope of practice, are usually concerned with being forced to juggle a schedule full of complex patients, with no cognitive respite throughout the day. This, however, is highly unlikely. If you subtract the healthy and easy patients from your schedule, they are not going to be magically replaced by an equal number of very sick individuals. Instead of 25 to 30 spurts of quick encounters, you are more likely to experience 12 to 15 long visits per day. Is that so bad?

It is very bad if your pay rate stays the same. It is spectacularly good if it doubles and triples. Whereas primary care physicians of the past are trapped in high-volume hamster wheel races, the new family docs, internists and pediatricians will be providing real value to their patients. Since the pundits are screaming from every rooftop that we should be transitioning from volume to value, this seems like a perfect arrangement for all stakeholders. Value, of course, needs to be valued, so paying, say, $300 for a doctor visit (not to be confused with primary care) sounds pretty respectable to me.

Corner drugstores are full of medicines and gadgets that used to be exclusively available from doctors. There is nothing new in transitioning tests and therapies into the hands of the lay public. You don’t have a microscope and a rabbit in your office, do you? Quit worrying about nurses and retail stores and the Internet stealing your lunch. You didn’t go to medical school to coach poor people on their sinful lifestyles and their need to be righteous and deserving of charity. You wanted to heal the sick, so have at it. If you want to fight for something, don’t fight for volume. Fight for value. Your value.

January 30, 2015

Healthy Vegan Caramel Slice

I've never seen myself as a particularly outgoing or even social creature really. It's not that I'm overly shy or anything, it's more of an active choice I've made to keep a smaller circle of close friends rather than being surrounded by a whole bunch of people whom I barely know at all. (Of course some people manage to have six hundred besties at once but needless to say, I'm not one of them. How do they even?) But thanks to Instagram I've had the opportunity to connect with and befriend so many amazing, inspiring and crazy talented girls from all over the world! How this little story relates to the raw caramel slice? Well this recipe would have never seen the light of day had it not been for one of these Instagram girls and her #twistmytreat competition.


 Who she is? Well the one and only EatLikeEloise of course! This slice was 100% inspired by hers and guess what? If you want in on this fabulous competition where you can win Loving Earth chocolates, all you have to do is reinvent or put a twist on Eloise's caramel slice! I'd do anything for chocolate hehe. Also, this is positively the best competition I've ever participated in. Look at that oozy caramel. Just look at it and tell me you don't agree.

One more thing before we get to the recipe: it looks longer and more complicated than it actually is! Mostly because I've included two different ways to make the chocolate layer. I was way too eager to get to taste this to bother making my own chocolate but if you want to keep this recipe raw, I highly recommend you spend those extra five minutes on this!



Base:

- 7 dates (around 80 g)

- 1/4 cup oat flour (30 g)

- 1 tbsp tahini (20 g)

Caramel layer:

- 10 fresh/soft dates (110 g)

- 2 heaped tbsp all natural peanut butter

- 2 tbsp unsweetened almond milk

- 1 tbsp lucuma powder

Chocolate layer raw version:

- 1 tbsp melted coconut oil or cacao butter

- 1 tbsp cacao powder

- 1 tbsp liquid sweetener of choice

Chocolate layer non-raw version:

- 2 oz. (56 g) vegan dark chocolate (preferably refined sugar-free)

How to:

1. Blend all the ingredients for the base in a food processor until you're left with a ball of raw 'cookie' dough. Add more oat flour if the dough is too sticky and more dates or tahini if it's too dry. (This depends a lot on how moist the dates are!)
2. Press it out into a small rectangle to about 1/4-inch or 5 mm thickness on a non-stick baking sheet. Set aside.
3. Peel and pit the dates for the caramel layer. This is easier if they have been soaked in hot water for at least 10 minutes or if you're using really soft ones. 
4. Place all the ingredients for the caramel layer in a small bowl and blend with a hand blender until smooth. (This step could be done using a food processor but I prefer the hand blender.)
5. Spoon the caramel on top of the base and level it with a spatula. Place in the freezer to set for at least one hour.
Raw version: 
6. When the caramel and base have set, make your own raw chocolate by mixing equal quantities coconut oil, cacao powder and sweetener in a bowl until combined. Wait until it's not super runny, then spread an even chocolate layer on top of the caramel. This will hopefully set immediately as the caramel is frozen so go ahead and cut as many slices as you want before placing them in an airtight container to store in the freezer or fridge if you prefer a gooey caramel.
Non-raw version:
6. If you're a lazy ass like me, then melt your (store-bought) chocolate over a hot water bath and spread it out on top of the frozen caramel base. It can be a bit trickier to cut neat squares this way (as is shown by the cracks on mine) but they're just as delicious, I promise. Store in the fridge for gooey caramel and the freezer if you want it solid.



Food Reward Friday

This week's lucky "winner"... the KFC Double Down Dog!!


Read more »

January 29, 2015

Creamy Chocolate Oats

Finally got this recipe up on the blog! A lot of you have asked how I make my everyday chocolate oats (literally every single day) and now the wait is over. It's not a revolutionising recipe or anything, just a simple but dangerously delicious and addictive one. Once you're stuck with one breakfast, it's hard to make a change. And let me tell you, I have been stuck with these oats for quite some time now. Hopefully you guys have more will power and determination than I have... 

Topped with banana slices, a peanut butter sauce and raw cacao nibs


Ingredients:

- 1/2 cup oats 

- 3/4 cup unsweetened almond milk

- 1/4 cup water

- 3 fresh dates (30-35 g)

- 1 heaped tbsp cacao or cocoa powder (or a tiny bit less if you find the taste too strong or bitter)

- salt to taste

How to:

1. In a small pot over low heat, bring the oats, almond milk, water and salt to the boil and let simmer. Stir often so the oats don't stick to the bottom.
2. As the oats are cooking, prepare your date paste. Peel and pit the dates, this is easier if you have really fresh, gooey dates or have soaked the dates in hot water for about 10 minutes beforehand.
3. Place the peeled dates in an itty bitty bowl or glass and mash them with a splash of water until smooth. (I like to use a shot glass for this!)
4. Transfer the date paste into the pot and stir until it's been well incorporated into the oats. 
5. Add the cocoa powder and stir again.
6. Let simmer until you have reached desired consistency, then spoon up in a bowl, add toppings of your choice and serve immediately!

January 27, 2015

Is Meat Unhealthy? Part VII

Looking at individual diseases is informative, but it can cause us to become myopic, making broad health-related decisions based on narrow information.  It can cause us to miss the forest for the trees.  In this case, the "trees" are individual diseases and the "forest" is total mortality: the overall risk of dying from any cause.  Does eating meat increase total mortality, shortening our lifespans?

Non-industrial cultures

Traditionally-living cultures such as hunter-gatherers and non-industrial agriculturalists are not the best way to answer this question, because their mean lifespans tend to be short regardless of diet.  This is due to ~30 percent infant mortality, which drags down the average, as well as a high risk of death in adulthood from infectious disease, accidents, and homicide/warfare.  It can also be difficult to accurately measure the age of such people, although there are reasonably good methods available.

However, there are semi-industrialized cultures that can help us answer this question, because they feature a somewhat traditional diet and lifestyle, combined with modern medicine and the rule of law.  The so-called Blue Zones, areas of exceptional health and longevity, fall into this category.  These include Sardinia, Italy; Okinawa, Japan; Loma Linda, California; Nicoya Peninsula, Costa Rica; and Icaria, Greece.

Read more »

January 23, 2015

Food Reward Friday

This week's lucky "winner"... barbecue ribs!!


Read more »

January 22, 2015

Pinwheel Cookies




Pinwheel Cookies

- 1/2 cup whole wheat spelt flour (65g)

- 1/3 cup almond flour (50g)

- 2/3 cup oat flour (87 g)

- 1 chia egg (1 tbsp ground chia seeds mixed with 3 tbsp water)

- 3 tbsp melted coconut oil (42 g)

For the chocolate dough:

- 1 tbsp cocoa or cacao powder

- 2 tbsp date syrup or any other dark syrup of your choice (40 g)

For the vanilla dough:

- 1 generous pinch pure vanilla powder (could sub for 1 tsp vanilla extract)

- 2 tbsp brown rice syrup or any other light syrup of your choice* (40 g)

How to:
1. Make the flour blend by mixing all the flours together with a fork. If you have to make flour of your oats and/or almonds, place the oats, almonds and spelt flour in a food processor and process until you get a well-ground flour.
2. Divide the flour mix into two different bowls. Transfer about 1/2 tbsp of flour from one bowl to the other. To this bowl, add the vanilla powder and to the other bowl (the one with less flour in it), add the cacao or cocoa powder and mix well.
3. Make your chia egg by mixing/whisking the ground chia seeds with 3 tbsp of water. This will swell pretty quickly if you're using ground chia seeds but if not, let the seeds swell for a couple of minutes before proceeding.
4. Melt the coconut oil and pour half of it into the chocolate bowl and the other half into the vanilla bowl. This is much easier if you have access to a kitchen scale so that you can tell when half of it has gone in. Also add chia egg into two and add one half into each bowl.
5. To the chocolate bowl, add the date syrup and stir until you have a thick dough. Repeat with the vanilla bowl but add brown rice syrup instead. *Note: Since brown rice syrup isn't as sweet as other syrups, you may want to add 1/2 tbsp of coconut sugar as well but that is completely up to you.
6. Wrap the doughs in cling film and chill for about 20 minutes in the fridge or until they're fairly firm.
7. Make one rectangle out of each dough by rolling it out with a rolling pin to 1/8-inch thickness. Put one on top of the other and roll lengthwise to create the swirl. Once again wrap the dough in cling film (reuse the old ones!) and place is in the freezer for about ten minutes.
8. Remove the dough from the freezer and slice into separate cookies (1/4-inch thick). At this stage I like to press down on the cookies using the bottom of a glass to flatten them out a little.
9. Bake in the oven (175C) for 18-20 minutes and let cool completely. Store in a cookie jar!







January 20, 2015

Artificial Intelligence

Did you know that the Ford Motor Company which created the first mass produced horseless carriage in 1908 is one of the largest manufacturers of automobiles a century later? Did you notice how cars today look almost the same as the Model T? They are all made of metal, have four wheels, a steering wheel, a dashboard, a windshield, two rows of seats and an engine. Closer inspection reveals that all newer car manufacturers make cars that look and feel just like the cars made by the Ford Motor Company. And they all drive on roads and use wheels, wheels, the hottest disruptive innovation of the Neolithic era. Truly disruptive innovation, unlike its short lived destructive cousins, stretches across millennia of useful applications.

Strangely enough, beds and tables and chairs, and the houses they furnish, look basically the same as those used by Louis XIV. Bread loaves and wine look the same too, and so do fishes. Another thing that hasn’t changed much from the beginning of time is the fertility of our collective imagination. At one time we imagined cherubs floating on clouds and magical beings who control the world and every single life within it. Entire industries sprung around that innovation, industries whose thought-leaders ruled the world in the name and on behalf of our imaginary hopes and mostly fears. For a while there, we decided that imagination is a personal thing and it should be separated from the mundane tangibles of our earthly affairs. That didn’t last long.

What separates us from the hapless creatures we are now killing by the bushel is the capacity and need to believe in something greater than ourselves, something that transcends our mortality and provides us with a purpose external to our own existence. First it was the certain belief in an omnipotent, and incomprehensible to mere mortals, intelligent design of the world we live in. Now it is the arrogant belief in our ability to create our future creator, an artificial intelligence to supersede our own, and to shape the world in ways beyond the wildest dreams of avarice and the trembling terrors of perdition’s flames. The age old puzzle of whether God can make a rock so big and heavy that even He cannot lift it, seems about to be resolved.

Suffering today, being beaten, tortured, starved and killed, is just fine, because after that comes your own personal Garden of Eden. Being unemployed, unemployable and living on meager handouts with no hope for a better future for you or your children, is perfectly fine, because after that comes “the eradication of disease and poverty”. Well, it is not “unfathomable” that it comes, and that’s pretty good, so go ahead and fathom amongst yourselves. And be afraid, very afraid, because unless you give us more money to study how we should go about doing the right thing, some really scary scenarios, such as having Gov. Schwarzenegger chase you in the middle of the night, are also fathomable. When? Sooner than you think, if you are still thinking, otherwise let’s say next Tuesday.

Stating that we are on the verge of creating artificial intelligence superior to the human brain, when we can't even make artificial chickens at this point, sounds a bit specious, doesn’t it? But that is not preventing us from incessantly talking and writing about it in order to generate the tried and true mixture of hopes for salvation, at an unspecified time in the future, with immediate and actionable fears of doing wrong today. We have magnificent prophets and we already have the heretics lined up as well. Did you ever wonder why some prophets had their litanies included in definitive compilations of bibles, while others were literally and figuratively burned at the stake? It may be helpful to look behind the curtains at those who anointed the prophets then and those who are anointing them now, because they are one and the same.

The job of prophets has always been to strip commoners of their ability to make independent decisions. Today’s prophets of disruptive innovation are showing us the road to becoming Roman patricians spending our entire lives sprawled on fainting couches while being fanned and fed gorgeous grapes by beautiful machines. The first thing we must do is to offload decision making to the precursor of the slave-savant machine of the future, so it can learn and practice the art and science of pleasuring us. Letting your GPS decide how to get from point A to point B is one example, and letting Google decide what you should read is another, although the latter may soon become obsolete, since enjoying grapes on your couch does not require any reading. Letting your “phone” decide when you should stand and when you should sit, when to eat and what to eat, and when you feel and how you feel is the next step in our evolution towards a perfect union between amino acids and silicon compounds.  

Perhaps nothing illustrates our glorious path to heaven on earth better than health care, and befittingly so, since health is life, hence health care is life care, is everything. The old definition of health care included mostly restorative medical activities to one’s health, but as the value of people keeps declining in an overpopulated global economy, and the costs of repairs are increasing, a more expansive, machine oriented, definition seems in order. People, you see, are essentially carbon-based machines, like say cars, the only analogy simpleminded voters seem to comprehend. To reduce your lifetime expenses on your car, and to enjoy a reliable vehicle for the duration, you need to have all the maintenance done on schedule (e.g. oil changes, tire rotation, filters, belts, etc.), drive carefully and obey the law, use the car sparingly, without too much starting and stopping, and you should wash and wax regularly, and generally keep it nice and clean inside and out.

You get the recommended preventive care for your model, all the screenings and tests, so any early signs of malfunction can be addressed, and you swallow all the recommended additives to make operations smooth and well lubricated, without undue stress to any of your parts, especially the feeble brain part. You refrain from reckless activities, and keep your mind and body clean on the inside and on the outside. The prophets, or futurists, as they prefer to be addressed today, are guiding us to all sorts of little silicon parts that we can incorporate in ourselves on the incremental road to transferring the limited intelligence functionality of biological creatures to superior artificial components. This simple process of artificial evolution towards a brighter future does not seem to come naturally to most people. These things never do. This is precisely why piety and obedience need to be enforced by cannons and laws, and here and there a few weaklings or outright skeptics must be made examples of what people should fear most.

Google is now making self-driving cars and in the future it will be making self-driving people. Whereas the self-driving Google cars look the same as those made by the Ford Motors Company, the futuristic self-driving Google people will look indistinguishable from the Neolithic geniuses who invented the wheel. And just like the Google cars are not really driving themselves, the Google people won’t either. Google is driving the cars and Google will be driving the people, and Google is driven by people. As it always has been and as it always shall be, a handful of megalomaniacal people will be driving masses of other people into hopeless existence, although, this time around, hopelessness should come with grape-dispensing machines and free happy pills.

Artificial intelligence is not autonomous machine intelligence. Artificial intelligence is not the fictional story of cyborgs roaming the earth. It is the story of the Wizard of Oz, the story of Stalin and Maoist reeducation, the story of Torquemada and the Dark Ages, the story of Egyptian Pharaohs and high priests clad in jewels accepting offerings from starving barefooted men while overseeing ritual sacrifices. It is the story of a cosmically inconsequential power trip that may set us back millennia instead of just centuries. At times like this, we should keep in mind that the true innovations driving humanity, and all cyclical prophecies of bliss and gloom along the way, were invented by men who were just slightly removed from apes.

January 15, 2015

Does high protein explain the low-carb "metabolic advantage"?

In 2012, David Ludwig's group published a paper that caused quite a stir in the diet-nutrition world (1).  They reported that under strict metabolic ward conditions, weight-reduced people have a higher calorie expenditure when eating a very low carbohydrate diet (10% CHO) than when eating a high-carbohydrate diet (60% CHO)*.

In other words, the group eating the low-carb diet burned more calories just sitting around, and the effect was substantial-- about 250 Calories per day.  This is basically the equivalent of an hour of moderate-intensity exercise per day, as Dr. Ludwig noted in interviews (2).  The observation is consistent with the claims of certain low-carbohydrate diet advocates that this dietary pattern confers a "metabolic advantage", allowing people to lose weight without cutting calorie intake-- although the study didn't actually show differences in body fatness.

In Dr. Ludwig's study, calorie intake was the same for all groups.  However, the study had an important catch that many people missed: the low-carbohydrate group ate 50 percent more protein than the other two groups (30% of calories vs. 20% of calories).  We know that protein can influence calorie expenditure, but can it account for such a large difference between groups?

Read more »

January 11, 2015

Frank Body Scrub - A Review

For the last two months or so, I've been using this unique body scrub called Frank. He's a pretty cool guy if I may say so myself. Not only because of his good looks but his inside as well. Frank is all natural, paraben-free and smells absolutely scrumptious. So forget about those nasty chemicals that you can't pronounce anyway. Pardon my French but this is the real shit that we're dealing with here.



The ingredient list is actually so simple that I can write it all in this post without boring you to death. Which is exactly what I intend to do. Frank contains: coffee, almond oil, water, salt, brown sugar, orange oil, vitamin E and natural fragrances. That's it. Are you impressed yet? As if that's not enough, this scrub leaves you with a scent as if a ginormous coffee bean with arms and legs were to give you a long, cuddly hug, and leave its dark, musky aroma for you to keep. Oh, it even brings out the hugely embarrassing poet residing deep within me.

How does it feel on your skin then? Well, amazing. There's no irritation at all plus the scrub leaves you soft as a baby's bottom even if you forget to apply body lotion afterwards. We have the almond and orange oils to thank for that I guess. I could also add that I have very sensitive, dry skin that won't stay silent if treated badly. I swell up like a balloon, get glowing red marks everywhere and physically hurt if I use the wrong products. Though I can't speak for everyone, I can certainly assure you that Frank has been very kind to my skin, unlike many of his counterparts.

I know what you're thinking now, "She is totally getting paid to write this!" Let me be 100% honest and say that I will not receive any compensation whatsoever for this post. Frank Body did send me a free sample of their scrub to try and review but that was it. Mark my words, I will never ever recommend anything that I don't believe in. Ever. I do turn down product proposals on a daily basis, just because I don't believe in what some companies have to offer. Anyways, I hope this post wasn't all too boring to read and that some of you might even find it helpful.

Have a great day!


January 07, 2015

Is Meat Unhealthy? Part VI

In this post, I'll examine the possible relationship between meat consumption and cancer risk.

Is cancer risk even modifiable?

Cancer is caused by the uncontrolled division of a population of rogue cells in the body.  These cells essentially evolve by natural selection to escape the body's multiple anti-cancer mechanisms.  

To a large extent, cancer appears to be a numbers game.  The human body contains about 37 trillion cells.  To get cancer, all you need is one cell that develops key mutations that allow it to shed its built-in restrictions on cell division.  The older you are, the more time you have to accumulate mutations, explaining why cancer risk rises sharply with age.

Unlike other common non-communicable diseases, we don't know to what extent cancer is caused by modifiable diet and lifestyle factors vs. bad luck that's completely outside our control.  Some cancers, such as lung cancer, are typically linked to lifestyle factors like cigarette smoking-- yet the majority of cancers aren't so easily understood.
Read more »

January 02, 2015

Food Reward Friday

This week's lucky "winner"... croissants!!


Read more »

January 01, 2015

What’s to Become of Primary Care? Or, Something to Do with Computers

You may not be ready to admit it even to yourself, but you know it’s changing. Permanently. Some say it’s for the better. Others say it’s for the worse. Most don’t really care much one way or the other. After all, health care has been evolving and changing over thousands of years, and the experts best positioned to evaluate the health care turmoil of our times are yet to be born. Those of us who are now in the eye of the storm have an understandable tendency to analyze high velocity changes, such as the number of uninsured or the number of hospital mergers, but the slower and more permanent changes are unfolding deep below the surface. Perhaps the most enduring alteration to what we call health care is the diminishment of medicine as a whole, and the fading importance of its practitioners, starting with the outer edges of primary care.

The “Looming” Primary Care Physician Shortage

We’ve been experiencing a “looming” primary care doctor shortage for several decades now, and so far it somehow failed to progress beyond the looming stage. The Affordable Care Act (ACA) is adding millions of previously uninsured citizens to the already swollen ranks of health care consumers, which is bound to exacerbate the shortage of primary care physicians, particularly as we move from sick care to health care, which is mostly to be provided by primary care facilities. As the public is wringing its hands in fear and apprehension, several solutions to this life-threatening shortage are being proposed and proactively implemented. The first and foremost solution is to allow non-physicians to provide primary care, whether in care teams with a physician figurehead in the corner office, or in retail settings at the grocery store. The second and longer term solution is the institution of remote medical care, provided by a mixture of outsourced physicians, non-physicians and algorithmic self-service apps.

The primary care shortage narrative is now as well established as death and taxes. Our constant inability to address this shortage is also immutable, and it has been so for all the decades we could have used to train more primary care doctors. Whether by design or by happenstance, we are now working hard to reduce demand, and perceived need, for actual doctors in primary care, and at the same time, we are working equally hard, if not harder, to increase the soothing volume of cheap and inconsequential services which are considered part of primary care. Ironically, it took many decades of random and often times planned decisions, made largely by the medical establishment to create this apparent discrepancy, and the pattern continues to this day.

Primary Care is Like Jiffy Lube

How often do you hear conservative doctors, still fighting the good old fight of 1965, stating that if your car insurance were to pay for oil changes, it would also cost a fortune? Insurance, you see, should be reserved for catastrophic events, and everything else should be paid with cash by each individual. And if the individual has no cash, then how many grocery stores would give you food (which is also lifesaving) if you had no money to pay for it? These positions are practically impossible to debate, particularly since personal charity is always the answer to opposing arguments. Oil changes and basic food are indeed planned and fully expected expenditures that each responsible person should budget for, and so are routine and non-catastrophic medical needs. But guess what else all these things appear to have in common? They are simple, undifferentiated, commoditized goods and services that anyone can provide, and many people can provide for themselves.

If primary care is to medicine what Jiffy Lube is to the automotive industry, we don’t need physicians to deliver primary care. Period. Even more astonishing is that this seems to be the main argument put forward by the direct primary care (DPC) movement. Previously known as concierge medicine, i.e. extra quality for more money, DPC makes the straightforward argument that good primary care is a cheap commodity made expensive by inordinate layers of insurance and bureaucratic regulation. For $60 a month or so, you can have all the primary care you can eat, if you pay directly to whoever employs your doctor, or if your purchasers (i.e. insurer or employer) do the same thing on your behalf, which renders direct primary care anything but direct, but that’s another story altogether. Strangely enough, I don’t see too many dermatologists stepping all over each other to convince us that what they do is worth very little money.

Divide and Conquer

Prof. George Weisz wrote a book titled “Divide and Conquer: A Comparative History of Medical Specialization”. I am not sure who was conquering what, but the slow current that will eventually wipe physicians out, as a profession, has its origins in the formally organized specialization of medicine.  Among the many theories and scientific justifications for the inevitability of specialization, Dr. Carl August Wunderlich observed as early as 1841 that “Now a specialty is a necessary condition for everybody who wants to become rich and famous rapidly”. The quest for fame and fortune, which has been our engine of advancement, has the localized consequence of turning each step forward into a giant zero sum game. For some physicians to become rich and famous, many others had to accept less wealth and lower status in society. And after kicking and screaming for a while, they all did.

In the beginning, a specialized physician was one who voluntarily chose to “restrict” or “limit” his practice to certain portions of general practice. In due course, general practice became involuntarily restricted to whatever specialists chose not to do. The scientific and largely elitist arguments of the nineteen century were used iteratively over time in increasingly contrived contexts, culminating with the late twentieth century expulsion of general practitioners from hospital care.  Hospitals today, although very different than hospitals in the nineteen century, are still the mechanism by which wealth and fame are accumulated in medicine. Agreeing to stay out of the cathedrals of medicine, pretty much sealed the fate of primary care.

Public Health

What is then left for primary care to do? I am certain this question is offensive to physicians practicing primary care. After all, it’s not just medicine that changed over the last couple of centuries. Disease itself was changed as a result. Today we have scores of people living with multiple chronic conditions, each one fatal on its own merit until not too long ago, and the generalist doctor is best positioned to manage the whole sick person. Some primary care physicians are still treading in specialist and hospitalist territories without apology and doing a great job at that too. However, the insidious slow current underneath it all, is not only continuing its menacing advance, but it is accelerating, because when physicians as a profession ceded control to specialists, they also invited into the tent other more powerful interests seeking their own riches and fame.

In the olden days physicians chose to specialize after they invented something, or became enthralled with new technologies or a certain group of diseases. Specialization allowed physicians to gain expertise using complex instruments and provided access to larger populations of people afflicted with whatever they were trying to study and improve. Scientific discovery in medicine followed the same pattern as in all other fields where groundbreaking research required an obsessively narrow focus. Excelling at one particular thing, as opposed to being adequate at everything, brought financial and personal rewards. This paradigm is being broken now by a brand new instrument – the computer, and by a brand new group of diseases – being alive. 

Just like the invention of the ophthalmoscope created the formal specialty of ophthalmology, the application of computers to medicine is creating the spanking new specialty of informatics, with one huge difference. Whereas the old specialization by organ, disease or instrument, was designed to narrow practice focus to subsets of patients, and small parts of each patient, informatics aims to expand its scope of practice to include every living person. Informatics is essentially the use of computers to practice an expansive and aggressive version of public health, which includes preventive, curative and research medicine. And thus, general practice on a much grander scale is resurrected, because old King Solomon was right and “that which has been is that which will be, and that which has been done is that which will be done”.

Something to do with Computers

That slow subterranean current that is changing medicine is the same one that changed and will continue to change everything we do into an industry. Nourishment became the food industry. Moving from place to place morphed into the travel industry, including automotive and aviation in its folds. Swapping is now the retail industry, and guarding one’s offspring and possessions became the defense industry. Some of these changes took thousands of years to complete, while others were executed seemingly overnight. Medicine is now engaged in its much delayed transformation to a healthcare (one word) industry.

The main difference between industries and the decentralized processes they replaced is that industries have captains, gurus, thought leaders and regulators, who rarely if ever interact with the masses serviced by the industry, i.e. consumers. The direct providers of industrial services are mostly laypeople, themselves consumers, rewarded with tokens they can use to cross-consume other industrial services. Fame and riches are reserved for the small but potent and irreplaceable captain class – the planners, the organizers and the administrators of industrial efficiency and productivity.

The stethoscope improved on a doctor’s ear, so he can more closely listen to a patient’s heart or lungs. The ophthalmoscope improved the vision of a specialist physician, so he can better see inside the eyes of each patient. The computer is improving the brains of all physicians, so they can treat entire populations without having to see, hear or touch any patients. Physicians specializing (or generalizing) in informatics are the captains of the emerging healthcare industry. The primacy of the general practitioner of old is finally being restored to the supremacy of the physician informaticist of new.

If the illustrious Dr. Wunderlich were to take the temperature of medicine today, he would indubitably observe that modern physicians, who want to become rich and famous rapidly, should find something to do with computers.