Welcome to the February/March issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being.
Before we get into the topic for this month, I wanted to share that I had a great response to an article I wrote for the Globe and Mail (Saturday edition) about the pitfalls of the ‘self-improvement’ industry, and had a chance to discuss it on the All Sorts Podcast with the very gracious Desiree Nielsen, RD (whose books you should read, and she has a brand new one as well). It was a wide-ranging interview/discussion, and Desiree’s questions were incredible. Hope you enjoy it. I also realized how much I use the filler words “you know” — will work on that! Consider it a fair warning!
Alright, the topic of this month’s newsletter, is the idea of ‘value-based care’ in healthcare — one of the most crucial concepts in healthcare today, in both the US and Canada.
But how do we define it? Atul Gawande penned an excellent article in the New Yorker several years ago which hits the main points in a very compelling way. Further, several years ago, the American Board of Internal Medicine (ABIM) Foundation launched the “Choosing Wisely” initiative in part to support value-based care and reduce wasteful procedures/treatments (including that which has little to no evidence of effect).
Value as it relates to ‘value based care’ (VBC) is defined as “the measured improvement in a person’s health outcomes for the cost of achieving that improvement.” It’s crucial to note that while reducing costs/waste is related to VBC, it can’t be equated to VBC — they aren’t the same thing.
This brings us to a more philosophical argument: what does “value” mean generally, and how does this concept apply to both our health, and the systems that support it (the obvious ‘healthcare system,’ but also the places we work and play and live)?
First we can ponder what value means to ‘health.’ We can probably agree that our ‘health’ is inherently valuable, as it’s derivative: without it we’re limited in actualizing our other needs. As such, we place high value on our health, and are willing to invest in it, though oftentimes it falls by the wayside. Our health is valuable as it links to surviving but also thriving — without our health, our quality of life suffers (the ‘how’ we live), and at the most extreme, we cease to live (ie we die).
But what about value in healthCARE, i.e. the delivery of services for the purposes of optimizing health/well-being and offsetting/treating morbidities? How might we define that? I think we can conceptualize it in a few different ways.
For one: we can use the Costco example (for my international readers: Costco is described here). Most people would agree that Costco is a place where people seek value for household goods (food, appliances, etc). Why? Because per unit its on average cheaper: the consumer pays less per unit, so Costco remains in business primarily due to this perception of delivering ‘value’ by selling products that themselves deliver ‘value.’ Bulk stores are similar: what we save on packaging ends up in our pocket. A good example is shampoo: 20% more for the same price. That’s value.
Effectively, getting MORE for less money, even if we shell out a bit more money at the outset is ‘value.’ It feels like we got a deal. But it’s more than just monetary. Part of assessing value involves something intrinsic and somewhat intangible. It involves a ‘feeling’ of receiving more than we bargained for (in a good way, to be sure). Think about the last time you went to a cash register and realized a purchase was on sale. Or if your local barista threw in an item (I see you: extra shot of espresso!) for free. Or when searching for a hotel or airline ticket you realize you’ve stumbled upon a deal that’s too good to pass up. That feeling is akin to value. We feel ‘good.’
Can this idea apply to healthcare?
Currently, according to the Centers for Medicare & Medicaid Services (CMS), the US spends just over $12,000 on healthcare per person, per year. COVID has brought this into full focus: spending increased by close to 10% in 2020. The US healthcare system is also one of the least cost-effective systems in the world (meaning more money spent with worse outcomes), especially compared with countries like Canada (where I’ve spent most of my life) and where I was born (United Kingdom). But why? Well a large fraction of spending goes to hospitals (31%) and doctors/primary care clinics (20%), and, as Gawande writes in his New Yorker piece, it’s very likely secondary to how physicians (and insurers, and hospital administrators) are incentivized. Wasteful procedures (and spending) become a byproduct of a mismatch between incentives and value.
Allow me to me share a few stories to illustrate this point.
First, up: as a patient. In June 2020, a few months into the pandemic, I broke my left wrist — a classic FOOSH in my NYC apartment. I was lucky in that it involved my non-dominant hand/wrist. I was also lucky to have a friend who is an ER Doc in the city (hi Dan!) and whom I could call right away as I laid there watching the soft tissues of my wrist swell up (ouch!). Dan kindly organized for me to see his colleague at the emergency department (ED) at a big teaching hospital a few blocks away for an Xray and splint. That was done quickly, and Dan’s colleague kindly allowed me to take a photo of my scans. The orthopedic surgeon resident advised that I’d likely just need a cast, based on the scans alone. Then I was referred, as per protocol in the ED, for a one-week followup with a staff orthopedic surgeon. So, a week later, I dutifully went. The surgeon knew I had a medical background and am a physician myself. What he didn’t know was that I has sent the X-ray images to Dan, my brother (An ER doc in Canada) and a few other friends in ED and Ortho (in Canada and the US) — every single one said, based on the X-ray and my verbal history of what happened, that the bone alignment was good and a cast alone would suffice.
But what did the surgeon in clinic advise? Surgery. He explained that I would run the risk of arthritis if I didn’t take this option, as an an active woman in her thirties, this may not be ideal.
What’s the cost difference between a cast for a wrist FOOSH and surgery. ENORMOUS. The ED visit and split, as well as the followup clinic visit amounted to $3,600 USD. Surgery on top would have been at least $10,000 (and that’s being conservative).
And surgery includes risks (of anesthesia, post-surgical infection of the soft tissue/bone, etc).
I was able to explain to the surgeon that I was returning to Canada within days and would prefer to have surgery there if needed. He resigned himself to an ‘ok.’
Back in Canada I was seen quickly and casted, had a great physiotherapist and was about 75% in terms of range of motion and weigh-bearing within 8 weeks, and 100% within 7 months (that last 25% was tricky).
What’s the lesson here? This was a glaring example of the differences in approach between Canada — which has a universal healthcare system and a different setup of ‘incentives,’ and the US. Not assuming ill intent, but was this surgeon aware that surgery would not in fact be better, especially considering the balance of risks and benefits, not to mention costs? Did he know that the risk of arthritis, according to the evidence, is equivocal between a cast and surgery? It’s unclear. But this was an experienced surgeon, so perhaps the incentive to recommend a relatively easy surgical procedure with a high payoff (to him and the hospital system) played a large role.
Now imagine doctors like him making similar recommendations — that is, ones that could be influenced by financial gain, not clinical evidence — to millions of Americans each year, Americans who do not have the privilege of having a medical background or someone they could turn to for an informal opinion before deciding.
This is how the US spends more on healthcare than most other industrialized nations.
Second story: as a doctor. A few years ago as a resident physician in the children’s hospital, I realized that the team was ordering daily ‘lytes’ (short for ‘electrolytes’) for every patient admitted on IV fluids. Allow me a brief digression: our bodies very tightly regulate sodium (Na) and potassium (K), among other things (bicarbonate/HCO3 and chloride/Cl for instance). Intravenous (IV) fluids are a mainstay of supportive care for many patients admitted to the hospital, as hydration is often an issue in we’re sick, due to fluid shifts, insensible losses, etc. IV fluids themselves, as they contain electrolytes, can also lead to ‘too much’ or ‘too little’ electrolytes (specifically K or Na) which can lead to all kinds of issues for the brain and the heart. For an illness like diabetic ketoacidosis (DKA), assessing electrolytes closely and comprehensively is very important for many reasons (more here, note that DKA is managed differently in children vs adults, but the general principle of close electrolyte monitoring remains the same).
But for other illnesses, namely ones that don’t involve massive shifts in electrolytes, and where the main concern is whether the patient could become hypernatremic (high Na) on an NaCl IV fluid, ordering a whole set of ‘lytes’ isn’t usually necessary: checking Na alone should suffice, and potentially, with good kidney function, checking every second day may also be reasonable. So why did the team order daily lytes on everyone on IV fluids? Again: it seemed to be an action that was incentivized, but not due to financial gain per se — it was likely an action incentivized secondary to ‘habit’ (i.e. ‘this is just what we do.’).
Why does this matter? Habits or shortcuts or heuristics save us from additional cognitive load. When we drive a car, we automatically know we need to stop at a red light, and go at the greenlight. We don’t stop to ask ourselves consciously whether we should stop or go (yellow lights on the other hand…). Stopping to think ‘does this patient need this action? Will ordering X change the course of management?’ are important questions, but they take time and effort. It’s often easier, especially in a busy hospital ward, to go into automatic mode and simply order more than what’s actually needed. The idea being: it’s better to be more comprehensive than not.
Except: that assumption is often wrong for patients who are clinically improving.
With this particular example of ‘daily lytes’, out of curiosity, I wondered about two things:
1. What was difference is in terms of volume of blood taken for a patient if we ordered ‘all lytes’ compared with just the one we needed (Na) in this case?
2. What was the cost difference between the two?
So, after a hasty lunch one day, I headed down to the lab second floor and asked a technician, who provided me with a list of costs. I also spoke with a phlebotomist to understand the blood volume issue.
Here’s what I found: blood volume wise, the difference was small, but there was still a difference — a few milliliters per tube of blood taken. Iatrogenic (hospital caused) anemia remains an issue in acute care medicine, secondary to taking too much blood from a patient. For a patient in hospital for a week, a few milliliters a day can be significant enough to cause symptoms (fatigue for instance, on top of what may be normal secondary to an illness).
Cost-wise, the difference was about $5. I can’t recall the exact figures, but each electrolyte was roughly $1 dollar (for ease of explanation I’ll assume equivalence between the Canadian and US dollar). A full lytes panel of 6 electrolytes costs $6. What does this mean? Let’s assume that each patient admitted to hospital requires a full lytes panel on admission, but then those that receive IV fluids only need their Na checked each day after. If the average stay is about 4 additional days on the inpatient unit, we’re dealing with a difference per patient of $5 a day — so $20 in total (with the total cost being $26 if we add that day 1 panel cost). Now imagine there are 500 patients admitted per month into the unit who require IV fluids. Thats 500 x $20 (=$10,000) compared with 500 x $4 (=$2000). Now multiply that by 12 to get the yearly figures, and then by the number of acute care wards in the country and….well you get the point. The financial difference that results from being more prudent with test-ordering is immense. The consequences of not stopping to think if there could be a better, less wasteful (and potentially less harmful, if we consider the volume of blood lost) way of delivering care results in the opposite of value-based care. Mind you: this is one example, of which there are thousands — as such the it’s not surprising that the waste we’re considering is into the millions if not billions. It’s the price we pay for physician/institutional inertia.
Last example — the everyday patient. In June 2021 I was visiting upstate New York, and had a really interesting chat with a taxi driver (as an aside: some of my most interesting chats about healthcare happen to be with ride-share and taxi drivers). I’ll call him Dale, and the moment I entered his car he launched into a discussion about the American healthcare system. In his 70s, Dale is a blue-collar worker with a grade 10 education. He also served in the military for several years, including in Vietnam. Dale has several chronic health issues, including Type 2 diabetes that’s poorly managed and requires insulin, high blood pressure, and high cholesterol. Recently his Medicare coverage stopped covering his insulin. This led to a very frank discussion with his primary care doctor, and Dale explained to me that he had all but “given up” and accepted that ‘death was around the corner’ (without insulin a patient with uncontrolled diabetes can go into organ failure and die). It was a very tragic example and a story that has stuck with me. Here we have an example of where, despite the high cost of care per patient in the US, we still have millions of people like Dale, who actually need the spending, who fall through the cracks, and adopt an almost resigned/pessimistic view of their longterm healthcare.
All three of these stories help us understand the puzzle pieces behind what we know as “value-based care.” But there is one more story that’s crucial, and particularly topical now: that of physician ‘burnout’ (aka anxiety, depression, etc) secondary to buckling under the pressures of performance, including the expectation to provide ‘value based care.’ When I mentioned cognitive load and institutional inertia/physician inertia earlier, it was because we must also understand that both of these concepts are in term impacted by the well-being of the physician. A stressed- out, unsupported, demoralized healthcare professional is unlikely to have either the time or the energy to stop to re-evaluate if they are ordering the appropriate test, or more broadly if they are providing the best possible care — one that maximizes outcomes for the patient and minimizes costs (not to mention makes the physician ‘feel’ like they’re making a difference).
Value-based care, in other words, must also, as it’s core assumption, place ‘value’ on physician health and well-being. It should be easier to provide value-based patient care, not more difficult, and there is value inherent in ensuring the physician feels good, remains healthy and thriving before/during/after delivering patient care.
Now that I’ve [hopefully] painted the problem clearly, we can agree that the *system* has to change. But for it to change in a sustainable way, the tweaks can’t just be topdown — from government or insurers for instance. We need to be thinking more creatively, like an entrepreneur. We need to ask how, to paraphrase Buckminster Fuller, of ways in which we can make the old system of how physicians are incentivized to deliver care, obsolete. The only way to do that is to create a better system, one that provides incentives that align with what doctors value.
Is there a way to provide value-based care while optimizing physician health/well-being and cutting down on unnecessary time wasted on administrative tasks? Yes.
Is there a way to improve patient outcomes while lowering costs, saving the most money on complex procedures that are actually needed. Yes.
Could this also involve taking a more whole-person/patient approach to healthcare? Yes.
So what might this potentially ‘better system’ look like? That’s the topic of the next newsletter, and an exciting announcement I have about a pivot in my own professional focus.
Have a healthy, joyful, and safe month,
Amitha Kalaichandran, M.D., M.H.S.
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Welcome to the November issue of WonderWell, a newsletter intended to gather the most groundbreaking research and insightful commentaries in evidence-based medicine, wellness, healthcare leadership, writing, and innovation to help you live and work in alignment with your purpose and well-being.
Some things that had me wondering last month:
1. COVID and…
Counterfeit: from STATNews — the frightening burgeoning secondary industry of fake vaccines and COVID medicines.
Children: in the NYT, preparing them for the trauma of COVID, and (an oped from the American Academy of Pediatrics) preparing ourselves for their vaccines in the NYT
What it will take to end the pandemic: A smart, and pragmatic, take from Leana Wen, in the WashPo.
Rapid tests: First read this eye-opening tweet thread by David Leonhardt (of the NYT) about issues with accessing rapid tests in the US (also applies to Canada), then read this profile of Michael Mina, an early proponent of these tests, in Bloomberg. For what it’s worth, it does seem that access to free rapid tests is around the corner for North America (below, an example from London, where the NHS provides them for free).
2. Podcasts (& shows/books) worth listening to/watching
Not a podcast or show or book (Sadly I have started nothing new this month…) but I did really love Ryan Holiday’s newsletter (a yearly one he puts out for his birthday).
This is from the archive but it made me think and re-think.
Lastly, I was very late to this viral piece, “The Bad Art Friend,” but finally listened to it on The Daily, and it was immensely horrifying and sad. In my view, there’s no question who the person in the wrong was: Dawn Dorland was gaslit and tormented for years — make no mistake: this was not an impulsive petty comment or bit of gossip. It was an orchestrated campaign over years to take her story, and associated themes around it (including perhaps the question of altruism vs validation — a great film about this theme is underway), her own words, with the goal of profiting off of it and dehumanizing her. Brene Brown discusses the idea of “common enemy intimacy” — this was certainly at play here: a group of very insecure writers, or perhaps a group of neutral writers, who were swayed (groupthink/social psychology stuff) by an individual with sociopathic and/or Machiavellian tendencies to partake in this abuse and gaslighting. It’s all made worse by two things: that Dawn had openly disclosed her trauma and mistrust (and they did it anyway, to re-traumatize her) and that the perpetrator used the excuse of being a woman of color as a way to paint Dawn as a person abusing her ‘white privilege’ (which only does harm to legitimate claims of bias and systemic racism in writing and beyond).
I’m hopeful Dawn will find justice, and more importantly, healing. I also hope this experience might plant the seed for her own memoir — could this just be a turning point in a fascinating story about altruism, kidney donation, and healing from trauma? I hope so.
3.On…when to quit (not grit)
In the NYT Opinion section, an incredible ‘video oped’ from Lindsay Crouse, on video when to quit (over grit).
4.Sound (and wise) reflections
This is very old (if May 2021 is old), and sadly I just found it a few weeks ago, but it’s one of the best ‘think pieces’ about the pandemic, in the Tyee (which is Canadian!).
Dr Eric Warm’s paper on game theory and the Match is well worth the time and introspection. The only thing that might have made it a bit better: incorporating the “Secretary Problem,” which someone told me about a month ago, and I can’t get enough out of my head (it’s brilliant…and applicable to many things).
Somewhat unrelated to this, is the “Avocado Problem” (which I believe I just made up…but I’m anxious to google it, in case it isn’t exactly original). It began with this….(M & S is a fine food shop, part of Marks & Spencers)…..read on and tell me if there’s anything to this…(by the way — it’s great that they specify that the ‘eat now’ avocado and the ‘eat later’ one are from two different places…)
It begins with a question: is there an optimum number of avocados that one (a buyer) can purchase in order to maximize satisfaction (having a ripe avocado to eat relatively soon) and minimize distress (buying an overripe one accidentally, buying an underripe one that needs time…i.e. cannot be eaten when the buyer wants)? I believe M+S has solved this. The optimum number is exactly 2, but one must be ‘ready to eat’ and the other slightly unripe. Why? Let us assume that most people who buy avocados imagine themselves eating it later that day (guac, snack) or the following morning (avocado toast, huevos rancheros). That leaves a window of 8-12 hours for pleasant consumption. Let’s also assume that most people who buy avocados dont like to go shopping for them daily. We rarely buy apples one at a time, right? But apples are not avocados (forget oranges)…more on that later.
Ok so now we have a person who wants to buy an avocado for imminent consumption but *also* has planned to eat another one within the next few days. Placing household size aside for a moment (but we would multiply the stable answer by the number in a household), the stable answer is 2: one ripe, one unripe (preferably not in the wasteful/plastic package as above, but individually). So why do grocery stories sell them as 5-7 in that green netting? Everytime I’ve given in to ‘buy more to save more’ idea, with avocados only (not apples!) I’ve regretted it. Why? Because avocados ripen more or less at the same time when they are sold like that — it’s the ethylene gas they give off to one another. So while we *think* buying more is better, the net outcome is roughly 3 edible avocados, with 3-4 going to waste. (again: not the same for apples, oranges, etc…avocados are among the most temperamental and unforgiving of fruits!).
Now you might be wondering…what does this have to do with a newsletter about well-being and health? Everything! Because so much of our well-being deals with *how* we make decisions. Not the *what* (outcome isn’t relevant here) but the process. Good decisions heighten our well-being (regardless of the outcome) because we minimize regret around the counterfactual. Bad decisions: the opposite. We weigh a variety of factors differently when we make decisions, and there’s also an element of chance (read anything by Annie Duke, like this or this, to get more insight into this — her work has shifted my perspective immensely over the last 18 months). Apples, you’ll recall, are not avocados. Apples are one of the most forgiving and stable of fruits — the time window to consume them is relatively long (a week or more) as opposed to short (avocados: hours !). That’s why buying apples in bulk makes sense: you can trust there’s one available for immediate consumption, and one (or many) for later. It doesn’t become a frantic exercise in planning and calculating….as it does for avocados. When we make decisions: about picking the right professional opportunity, business/romantic partner, etc, we weigh some of these same factors. And a big one, beyond compatibility around values etc is *timing*. The problem is that we often presume that these opportunities are like apples: ready when we are, and if we aren’t ready they will still be around when we are; as humans we tend to over-emphasize our own sense of timing and time more generally. This is, obviously, wrong.
Most things (opportunities, people we may want to partner with) are like avocados: If we’re ready (timing wise), we ‘match’ to the right opportunity that might be ready (ripe) as well, except that there’s also the element of uncertainty and chance: that ripe opportunity may not be all it that it seems (the ripe opportunity may end up being overripe/rotten when we finally dig in…which we perhaps didn’t judge well beforehand) OR, since we dont function in isolation but with other people, others may jump at that ripe opportunity before us. As such, the most stable solution is to pursue the ‘ripe’ one, but have a somewhat ‘unripe’ one in the wings. Note: this isn’t the same as having a backup plan: a backup plan is effectively like lining up two ripe things one after another — having something in the wings that isn’t totally ‘ripe’ (either the opportunity is still in flux, or you are still somewhat unsure), but could be sorted out over a period of time is better (this means that we also avoid the competition element).
Thanks M&S Simply Food for sponsoring this not-so-simple digression (kidding). And yes, I know avocados are not the most sustainable fruit…but let’s park that for now, for the sake of this thought experiment.
6.Best tweets of the month goes to…
Adam Grant on prestige and jobs
Sahil Bloom on following your curiosity
Maria Popova on living just the one life
Amy Edmondson on…cookies 🙂
7.Products/Services that have made a meaningful difference during the pandemic:
This newsletter is not sponsored, but I love sharing products that have made a meaningful difference in my day to day (increased productivity, more joy, etc). This month I’m sharing my absolute favorite tea: Marco Polo by Mariage Freres.
I discovered it at a friend’s house in 2016, in Cabbagetown Toronto — the teabags are just sublime and a bit over the top (think: linen). I managed to find the loose tea version at Pottery Barn of all places, but paid a visit to the Covent Garden location recently and picked up some more teabags, and have made a few cups for friends here. It’s a black tea with a fruity essence, and is simply delicious with or without honey/milk — perfect post dinner, pre conversation tincture 😍
In My Own Words…
I just completed my reporting for a longform piece I’m working on for Wired (now the writing begins), and gave keynote talk for the National Partnership for Hospital and Hospice Innovation (their Summit is underway), on the topic of burnout and healthcare revolutions (I’ll share the video next month). Funny enough, my mother sent me a photo from London (where I am for another 10 days) from the late 1980s — my first ever keynote! Thankfully my audience was slightly larger this time around, and I found a nicer bookshelf.
I also had a chance to visit my old house (where I lived from about 2 to 6 years old), a duplex in Welling, Kent: 24 Clifton Road. It was really fun to chat with one of the neighbours and get all caught up on the neighbourhood happenings over the last couple of decades! I also retraced my walk to primary school — I’m a bit dumbfounded at how long it was (about 20 min for an adult, so 35 min for a 6 year old?)
Have a healthy, joyful, and safe November,
Amitha Kalaichandran, M.D., M.H.S.