Health and the 2016 US Presidential Candidates

The 2016 Presidential Campaign is nearing its end; in only two weeks American voters will decide who, most likely Hillary Clinton or Donald Trump, will sit in the Oval Office. The US presidency is a hard job, with grueling hours and the need to make critical decisions at any time, day or night. Campaigning for president is itself a tough physical endeavor, one that speaks loudly of the health of the candidates. This year has been especially bitter, with accusations and recriminations more appropriate to a college dorm than to the highest office in the land.

My primary work is as a family, preventive, and sports medicine physician. During this season, many people have asked me what I think of the health of the candidates. On one hand, I am not the personal physician of either candidate. I have never met either of them, much less taken a medical history or performed a physical. Any opinion that I render is dependent on publicly available medical information and observations that I have made from afar. On the other hand, the coverage does provide a great deal of data. For the sake of my friends and readers, who have asked me repeatedly, I will give an opinion.

Donald Trump

An article on CNN dated 15 Sept 2016 states that Trump is 70 years old, stands 6’3” and weighs 236 lbs, giving him a body mass index of 29.5.[1] By medical standards, he is overweight and therefore is at higher risk for diabetes, heart disease, and various types of cancer than Americans with a BMI between 21 and 25. A recent blood pressure was 116/70, remarkably good for a 70-year-old unless he is on medication, and is fasting blood sugar is 99 (normal is around 100). Trump takes Rosuvastatin for high cholesterol and triglycerides (the fat in his blood), and recent triglyceride results were 61, which is normal.[2] He also takes a low dose aspirin for cardioprotection. Trump’s latest liver function tests, thyroid tests, electrocardiogram (ECG), and chest xray were normal. His colonoscopy (2013) and transthoracic echocardiogram (2014) were also normal. These results suggest that Donald Trump is in good health for a man his age, although I have not seen independent confirmation.

Observations are also important. The human gait changes over time, with stride length diminishing and pace slowing. Medical students are often taught that “gait is the signature of the nervous system.” Trump’s gait is essentially normal, comparable to those of other older presidential candidates such as Ronald Reagan and Bob Dole. His facial expressions and muscle movements are equal and fluid, suggesting a normal nervous system.

His posture is fair, but he rolls his shoulders in, as most people do. Thus Trump is at higher risk for shoulder weakness and chronic pain, although I was not able to find a picture of him without shirts or shoes on the internet.  Given his age and weight, Trump is at high risk for arthritis of his weight bearing joints, especially his knees, hips, and spine.

Trump’s mental health has been the source of speculation and scorn for thousands of talking heads. His statements certainly come across as arrogant, but the same can be said for most billionaires, politicians, and otherwise prominent people. Some have suggested that arrogance is a prerequisite to run for president. Though a character flaw, arrogance is not a diagnosis. Narcissism, the excessive admiration of one’s own attributes, is a diagnosis that has been applied to Trump, but could equally well be applied to most rich, famous, and powerful people.

Hillary Clinton

On 14 Sep 2016 Dr. Lisa Bardak, Hillary Clinton’s attending physician, states that the 68-year-old Clinton is “healthy and fit to serve as President of the United States.”[3] It mentions her having sinusitis and a left ear infection in Jan 2016, for which she received a CT scan of the sinuses and brain as well as antibiotics and a myringotomy tube (ear tube). Clinton received antibiotics again for a “right middle lobe pneumonia” in Sep 2016. Bardak notes that she “felt dizzy” at a 9/11 commemoration event, and gradually improved. Clinton has hypothyroidism (treated with Armor Thyroid), Coumadin (which Bardak did not explain), and vitamin B12. Her other results are as follows:

“Of note, she has remained stable for many years on Armor thyroid to treat her hypothyroidism (a low T3 level).  Her laboratory testing (vitamin D, CBC, fasting blood glucose, comprehensive metabolic panel, hemoglobin A1-C, vitamin B12) was normal, including cholesterol of 189, LDL of 103, HDL of 56 and triglycerides of 159. Her vital signs showed a blood pressure of 100/70, heart rate of 70, respiratory rate of 18, temperature of 97.8, and pulse-oximetry (oxygen dissolved in the blood) of 99%.[4]

Hillary’s publicly available health history includes the following:

Coughing fits

Coughing fits can be due to many conditions, ranging from allergies to acid reflux to serious respiratory disease. Hillary has had several episodes of these fits. She also suffers from hoarseness, which can be related. Dr. Bardak states that Clinton has had allergies for many years and that they are controlled on Clarinex, an antihistamine.[5]

Right elbow fracture

While serving as Secretary of State in 2009, Clinton fell and fractured her elbow in the basement of the State Department. The fracture had to be significant because she underwent surgery to fix it. A small, non-displaced fracture would likely have been treated non-operatively. White women are at high risk for osteopenia and osteoporosis (thin bones). Epidemiologically speaking she probably has both, and this may have contributed to the severity of the fracture. By contrast, in the 1996 campaign, for example, a 73-year-old Bob Dole leaned on a fake railing at a campaign event, which gave way. He fell three feet to the floor and hit his right side and arm but was not seriously injured.

Secretary Clinton is not thin, which lowers her risk for osteoporosis, but raises her risk for high blood pressure, diabetes, heart disease, and various types of cancer. Fortunately for her, the blood pressure and HgbA1C are normal.

A bigger question is why she fell. It could have been something as simple as tripping over a rug. Standing equilibrium decreases with age, as does vision, muscle strength, and many other factors that protect against falls. Past falls are a significant predictor of future falls.

Fainting and Traumatic Brain Injury

In late 2012, Clinton fainted and hit her head, sustaining what was then announced as a concussion. The State Department suggested that a stomach virus and subsequent dehydration caused the fall. She had chronic headaches after the fall and in December a follow up brain scan revealed the presence of a subdural hematoma, a collection of blood between the brain and the skull. This reveals that the blow to the brain was far more significant than originally thought. Her history is significant for a blood clot in her right leg in 1998, which means that she may have a genetic tendency to get blood clots easily. Clinton began taking Coumadin, a blood thinner which she continues today. Clinton’s head CT in January was probably a follow up on her brain injury in 2012.

In January 2013, observers noted that Clinton was wearing glasses with a Fresnel Prism, used to treat double vision.[6] This was likely related to the fall in the previous December.

Pneumonia and Near Collapse

While getting into a black van after a 9/11 commemoration ceremony in Manhattan, Hillary nearly fell to the ground several times. Had she not been physically held up by supporters and Secret Service agents, she would have fallen.[7] The video begins with Clinton leaning against a metal bollard with a woman holding Clinton. As Hillary moves she slumps, is caught by the Secret Service, and slumps twice more. Her head bobs several times. She lost a shoe while being whisked away. Common causes of such symptoms include dehydration, as in the earlier episode, heart conditions, and seizures. Dehydration is the most likely culprit, although Clinton’s history of brain injury elevates her risk of seizures, and her family history of heart disease is also concerning.

Sometimes Clinton’s upper body movement seems normal, and other times she seems to be supporting herself with a podium. Sometimes her step length seems normal, and other times it seems short and halting. Even at her best, such as during the second presidential debate, she looked repeatedly at her feet while walking. Each step was carefully placed. This suggests that her balance is poor and she needs visual cues to stay upright. She sat every time that she could while Trump stood without support during many intervals.

Other notes

Some may argue that the president’s health is less important because a president has access to the best medical care in the world. Having worked with the White House Medical Unit on more than one occasion, I appreciate their dedication and professionalism; working long hours and traveling anywhere with little notice. The volume and variety of patients that they see is low compared to many primary care clinics, but their training is excellent.

Whether or not presidents have access to the best medical care in the world, they certainly have access to the most medical care in the world. Powerful people tend to want to stay powerful, and since their power is related to their work, they are impatient with the healing process. They want short cuts, usually in the form of more interventions, more drugs, and more procedures. To some extent this is true of everyone, but powerful people are able to get what they want. Often this is harmful.

Health care professionals wittingly or unwittingly collude to give presidents more health care than they need. Lincoln and Garfield might have survived had their physicians, in well-intentioned zeal, not probed to get the bullets that killed them. Even Bardak’s reassuring letter notes that Clinton got more care, not necessarily better care, than most people would for the same conditions. A single ear infection, even if it is persistent for a few weeks, is not an indication for a myringotomy tube. A sinus infection is not an indication for a brain CT scan, although it may have been done because of her prior subdural hematoma. Most people with pneumonia never get or need a CT scan, and a temperature of 99.4 is not indicative of a fever (100.4 is the generally accepted cut off for healthy patients). Clinton sustained the risks of relatively high medical doses of radiation and the risks of surgery, perhaps unnecessarily. More care does not equal better care.

This is not to blame Mrs. Clinton or her team; the pressures on a presidential candidate are extreme, especially in this era of inescapable public attention. High ranking generals, sports stars, and famous entertainers are also at high risk for getting more care, not necessarily better care. However well intended, this exposes them to risks that can be a detriment to good health.

Limitations

As I mentioned above, I am not the physician for either Donald Trump or Hillary Clinton. I have never examined or even spoken to either. The information that I have reviewed is a small sample of all of the information available about these people. I am writing at the request of friends and readers. The question about the health of the presidential candidates is important.

Conclusion

Does Trump’s health disqualify him from being president? No. Does Hillary’s health disqualify her from being president? No. President William Henry Harrison caught pneumonia and died within 40 days of taking office, and it is unlikely that either Trump or Clinton will do the same. Franklin Delano Roosevelt was crippled from polio his entire presidency, a fact concealed by the media of his day, but he was an effective president. Nonetheless, just like an employer needs to know if the applicant sitting in front of her is physically capable of doing the job, voters need to know if their two applicants, Donald Trump and Hillary Clinton, are physically capable of doing the job.

Donald Trump shows no evidence of being physically unable to be the President of the United States. Voters can choose against him for a variety of reasons, but his physical health probably should not be one of them. He seems to be as healthy as past candidates of similar age, including Ronald Reagan and Bob Dole.

Hillary Clinton’s health is more concerning. She has many medical problems both past and present. Some of these are very serious. She has current symptoms possibly consistent with ongoing neurological impairment. She does not appear to be as healthy as past candidates of similar age. Voters will decide if Clinton is healthy enough to receive their vote.

Whichever candidate wins, time will tell if they were healthy enough to serve as president.

 

[1] http://www.cnn.com/2016/09/15/health/donald-trump-health/index.html

[2] http://www.nytimes.com/2016/09/19/us/politics/donald-trump-health.html?_r=0

[3] https://m.hrc.onl/secretary/10-documents/05-physician-letter/HRC_physician_letter.pdf

[4] https://m.hrc.onl/secretary/10-documents/05-physician-letter/HRC_physician_letter.pdf

[5] https://m.hrc.onl/secretary/10-documents/05-physician-letter/HRC_physician_letter.pdf

[6] http://www.foxnews.com/health/2014/05/16/ophthalmologist-weighs-in-on-clinton-glasses-spectacle.html

[7] http://nypost.com/2016/09/11/hillary-clinton-has-medical-episode-at-911-ceremony/

Do We Hate Our Bodies?

The other day I read an article written by a hospice chaplain from South Carolina entitled “What the dying really regret.” The author interviewed an elderly woman who was dying of cancer, who said:

“I know I’m supposed to hate my body…Everyone told me — my family, my school, my church. When I got older, magazines and salesgirls and boyfriends (told me), even if they didn’t say so out loud. The world’s been telling me for 75 years that my body is bad. First for being female, then for being fat and then for being sick…But the one thing I never did understand is, why does everyone else want me to hate my body? What does it matter to them?” Kerry Egan, CNN, 17 Oct 2014

The author concluded that the dying regret losing their bodies, and that makes the fact that society teaches us to hate our bodies all the sadder. Bodies decay over time; my grandmother memorably said that she felt like an 18 year old girl in an 80 year old body, but they are still the only thing that connects us to the material world.

Do people hate their bodies? Sometimes, yes. As a sports medicine physician I take care of anorexic athletes, thus far all female, in their teens and twenties, who perceive themselves as fat though they are wasting away. As a family medicine physician I have treated obesity in thousands of patients, including counseling them on how not to hate themselves for their weight. As a preventive medicine physician I have dealt with the larger problem of populations, whole groups of people, abusing their bodies and living unhealthy lifestyles in part to compensate for self-dissatisfaction. As a Christian minister I have counseled people who struggled with terrible feelings of inferiority, in part because of the look of their bodies.

Are people taught by society to hate their bodies? Often, yes. Advertisers use all of the formidable tools of psychology and manipulation to convince people that they are inadequate so that those people will buy their product in the (ultimately vain) hope of becoming adequate. The messages are compelling;

  1. You won’t find love in the world because you teeth aren’t white enough, so buy this product.
  2. You can’t be happy because your hair is too gray so buy this product
  3. Your will never be healthy and will die young because your body is too fat so buy this product.
  4. Look at the phenomenally beautiful woman (who is a genetic rarity, eats nearly nothing, works out constantly, and has an army of people to help with her hair, makeup and clothes) in this picture (which has been airbrushed and edited to eliminate any flaw)! Why can’t you look like her?

In the past this drum beat came to us through radio, television and print media but since we did not have these with us constantly, we had a respite from the message. Now with smart phones and other portable devices, we have no relief from hearing all that is wrong with us, physically and in every other way.

Other people, often trying to make themselves feel better about their bodies, denigrate ours. The interviewee referred to men and women alike telling her, with and without words, and even with and without meaning to, that her body was bad. From trade in jade and silk between Europe and China in 2000 BC to modern body shaping underwear, fortunes have been made selling people things to try to make them more beautiful.

Sometimes even the church teaches people to hate their bodies. In Romans 7, Paul anguished about the sin in his own life, discussing the fact that sin is present in his flesh. He concluded with the statement “Wretched man that I am! Who will set me free from the body of this death (V24)?” The obvious conclusion is that the physical body is wicked and the spirit is good. Since we should hate sin, we should hate our bodies.

However obvious, this conclusion is absolutely wrong, rooted more in Platonic dualism and in Gnostic hatred of the material world than in Christianity. Furthermore it is not at all what Paul meant. The Hebrews recognized that God created the universe, including our bodies, and that His creation was good. They had a healthy respect for the body and had no concept of a disembodied life after death as the later Greeks did. Beginning around the time of Daniel, Jewish thought included bodily resurrection from the dead, not ghosts floating around the universe forever.

As heir to this heritage, Paul had the highest regard for the human body. He called it the temple of the Holy Spirit and taught his students to honor it (1 Corinthians 6:18-20). Paul told his disciple Timothy that though not as valuable as godliness, physical exercise was profitable (1 Timothy 4:8). His statements in Romans 7 were not that the material body was wicked, because the body was as much a victim of sin as was all creation (Romans 8:19-23). Rather, Paul wanted to be delivered from sin. If the body was the source of sin, the most effective (and macabre) way to deal with sin in life was to eliminate the body. The Bible never teaches this.

Another common misconception is that Christianity teaches women to be ashamed of their bodies because sexuality is wicked and their body might cause someone else to sin. First, sexuality was created by God and nothing that He made is evil. Second, the entire Biblical book of Song of Solomon is devoted to romantic love, the courtship and married life of a young couple. The book glorifies human love in the context of a man and woman married for life. Only outside this context does Scripture discourage sexuality. Third, when a man looks at a woman and lusts after her, that sin is his, not hers. However if the woman dresses immodestly because she wants to provoke envious or lustful thoughts in others, that sin is hers. The key is for men and women to dress in a way that pleases themselves while being more concerned with others’ needs than with his/her own, and being more interested in personal character than in physical appearance.

The body is our connection to the natural world, the place where we laugh, love, and live. It enables us to feel cool breezes on hot days, embrace our families and friends, taste delicious foods, and smell fragrant flowers. The body allows us to think, to speak, to work, and to serve God and others in the world; doing His work so that others may know Him. God made creation for His glory, for our care and for our enjoyment, and He gave us bodies to be a part of it. Someday we will lose our earthly bodies, and then regain them, clothed in glory and incorruptible, in the new earth.

Though advertisers will continue to tell us that we are never good enough, and some other people will forever try to build themselves up at our expense, our Creator tells us that He loves us infinitely as we are, regardless of how we look and what we can or cannot do. The Church can never teach its members to hate the body, and each pastor, leader and teacher must have the right understanding. If we are to love the Lord and love our neighbor, we can do no less.

How to Improve your Health and Health Care

Throughout Central Asia, the Middle East, and much of the developing world, people have told me that they cannot get good medical care. In some cases good care is too expensive, in other cases medical care is affordable but poor quality, and in still other cases medical care, good or bad, does not exist. Some friends with significant health care problems labor in austere conditions never knowing when a medical emergency will strike, and if they will be able to get help when and where they need.

Some people have similar problems in the developed world, even including the United States. America has been swept by debates about health care, especially about how to make quality health care available to all Americans. Medicare is a government single payer program for the elderly and Medicaid is the same for the poor, but these programs pay providers too little and yet are unsustainably expensive for the nation. The Affordable Care Act (ACA) was the most recent Federal attempt to improve Americans’ health, but the results have been mixed. Fundamentally the ACA was health insurance reform, not health care reform, and providing someone with an insurance card is not the same as providing them with health care. Hence we have millions who lost their insurance, millions who got new insurance, and millions waving their new insurance cards in the air who cannot get care because it doesn’t exist in their area, wait times are too long, or the system pays so little that providers cannot afford to take these patients.

Britain’s National Health Service, and single provider or single payer systems in Canada and Europe, also attempt to get health care to everyone in their population. While some of their outcomes are good, these systems ration care by long waits and care denials. Despite sometimes draconian cost saving measures such as denying cancer and heart disease treatments to the very old, these systems are still increasingly unaffordable.

Everyone needs health care, at least at home, in their lives, and most people need professional health care, such as that provided in clinics and hospitals, at some point. Professional health care must be affordable to the patient and family. Most people have neglected seeing the doctor, getting medications, or getting a blood test because in their perception the cost was greater than the benefit.

In some cases the needed professional health care is simply not available. As noted above, many Western expatriates in the developing world have no way to get Western quality medical care. Some people in rural areas throughout America and the world must travel hours or days to get to clinics or hospitals, and many don’t go as a result. This article will describe things that people can do to improve their health and health care.

How to Improve your Health

Historically, most medical care has been nursing care and has occurred in the home. The human body has a remarkable ability to heal itself, as long as it is well fed, sheltered and clean. The vast majority of routine illnesses and injuries will heal on their own without any intervention by the medical system.

Healthy bodies heal better and faster than unhealthy bodies. Volumes have been written about getting healthy, including the value of a good diet, exercise, and sleep, and the importance of avoiding tobacco, alcohol, and other unhealthy behaviors. This article will not revisit these messages. Clearly the most important way to improve your health care is to improve your health.

Having a healthy home is the second most important part of good health. Homes that are clean, safe and harmonious are generally homes with healthy people. When a parent smokes, the whole family is harmed by the smoke. When a parent uses alcohol, the whole family is more likely to suffer because of alcohol. When a home is dirty and unsafe and food is poor, everyone has a greater risk of illness and injury.

Another important factor in health is having a healthy and safe neighborhood. Accidents are the most common cause of death in children, and injuries afflict all ages. Yards, sidewalks, homes and schools should be safe and neighborhoods clean and well lit. More than governments, residents are responsible for the safety and health of their neighborhoods.

Certain lifestyle practices are associated with good health. We frequently hear that smoking and drinking alcohol are bad and exercise is good, but there are some more surprising changes that people can make to be healthier. Married people generally enjoy better health than unmarried ones, and people who attend religious services regularly are healthier than those who do not. Children also help people be healthier.

How to Improve your Professional Health Care

The Internet contains great information about health and health care, but it also contains misinformation. While proper use of the Internet can help people manage their care at home, misuse can cause anxiety, poor decisions, and bad health. The most important consideration in using the Internet for health care is to use reputable sites. The Virtual Medical Center at MDHarrisMD.com has reliable sites for patients, providers, health care administrators, and public health professionals.

Suppose your toddler has a fever and is fussy and you go to familydoctor.org. You click on the “symptoms” button and go to “fever in infants and children”. You then follow the algorithm. It tells you what to do for your child, when to seek care, and what kind of care to seek. These algorithms have been validated by many studies usually involving thousands of patients and you can rely on them.

For most people with a medical concern, their first reaction is to seek professional care; usually a visit with a provider. However there are many ways to get care without an appointment. Health care organizations often have telephonic Nurse Advice Lines where patients can get professional advice and care from registered nurses. Patients can often also call their primary care clinic to ask questions. Many medical practices have an online presence; websites that allow patients to check labs, renew prescriptions and ask questions in a secure web site. Many health care organizations allow patients to book appointments online. Some physicians even have online visits, in which patients can get an office visit from the comfort of their own home or office. Ask your doctor if he (or she) has an online presence and how you sign up for it.

For simple and short duration symptoms such as a cold, small retail clinics manned by midlevel practitioners such as physicians assistants and nurse practitioners provide reasonable service at bargain prices. They often also provide preventive health services such as sport physicals, but are not intended to manage complex medical conditions or long term care.

For most problems, go to a primary care clinic. Your primary care physician can handle over 90% of the most common concerns. Most patients do not need to see a dermatologist to remove a mole nor a gynecologist to perform a pap smear. Primary care physicians manage uncomplicated high blood pressure as well as cardiologists do, and early diabetes as well as endocrinologists. Neither uncomplicated acute back pain nor a sprained ankle requires a visit to an orthopedist. Insisting on a referral to a sub specialist wastes time and money for the patient, the practice, the community, and the health care system.

Take responsibility for your own health care. No one can coordinate your medical care better than you can, and no one will. Medicine is complicated but can be understood by anyone with the will to try. Those with genuine cognitive problems such as learning disabilities or early dementia may need family members or friends to help them, and communities, churches and other charitable groups can assist those truly alone. Medical practices, often caring for thousands of patients, can help, but no one can take the place of family and friends in assisting individuals in taking responsibility for their health.

At a visit, make sure that you fully understand your doctor’s instructions before you leave the office and understand how these instructions fit in with the overall plan of care. Shop for the best deal for ancillary studies like laboratory and radiology. If your doctor tells us that you need an MRI, ask him (or her) what vendors are available, what their quality is, and how much they charge. Just like you would do for any service, go to the place that best balances quality and price. If you are prescribed medications, ask your doctor to use generics and cheaper medicines when possible, as these are generally as effective as expensive, name brands. As a rule, do not ask for antibiotics; a competent physician will prescribe them when required. If not prescribed, they are probably not required.

Don’t neglect your preventive care. Immunizations are vital for good health, and vaccinations are generally safe. School and sports physicals are important for children, and prenatal care is indispensable for pregnant women and their not yet born children. Patients with chronic medical problems such as diabetes, high blood pressure, and high cholesterol need routine follow up.

Communicate with your professional health care team. Years ago I took my father to see his doctor. He had complained of fatigue and shortness of breath for months, but when his physician asked how he was doing, he replied “fine”. The doctor looked at him, undoubtedly wondering why he had scheduled the appointment. Unwilling to lose the opportunity, I listed dad’s real concerns and the visit became productive. Find a primary care practice that you like and stick with it, because consistent care is better and less expensive care. Many advisors tell patients to make a list of their health questions and worries and discuss them all with their doctor. While this may be reasonable, providers typically have no more 15-20 minutes with each patient and so may ask you which is the highest priority and handle only that one.

Unfortunately, some people have health care needs such as cancer which are beyond the ability of a primary care practice to manage alone. These patients should be managed jointly between their primary care provider and their subspecialty provider, like their oncologist. The need for routine primary care never goes away, so even patients with serious medical problems requiring specialty care need a primary care doctor. Medicine is more than a business, it is a relationship between a group of medical professionals, their patients and those patients’ families. Healing is physical, mental, social, and even spiritual. That is why for millennia and in every culture, the healer was often the priest, and the work of healing was associated with the transcendent power of God.

For people whose professional health care needs exceed the capability of their home and the local clinic, charitable and other private hospitals provide the best care. With some exceptions, such as combat casualty care and long distance medical evacuation, health care provided by governments is more expensive and less efficient than that provided in the private sector. Even for the sickest people, however, good health, home care, preventive care, and primary care are indispensable.

How to Save Money on Health Care (partly drawn from Kiplinger’s Personal Finance, Oct 2014)

Health Care and Ancillary Care Providers

  1. Pick a HCP in the network for your health plan. Your deductible and out of pocket expenses will be much lower.
  2. Find out which physicians are “super-preferred” providers in your health plan, usually because of high quality, cost efficient care. You may pay even less.
  3. Comparison shop between radiology centers. The stand-alone centers are often cheaper and have greater price transparency.
  4. If you need a surgery, ask your surgeon about which ones have the lowest cost while maintaining high quality.
  5. Investigate which hospitals and urgent care centers are in the network for your insurance when you first get the policy. That way you will know where to go when the urgent problem strikes.
  6. Independent labs, like independent radiology centers, often have greater price transparency and lower prices than hospital based ones while maintaining high quality.
  7. Consider telemedicine, which uses technology to produce virtual doctor visits and video visits, often at a lower price than going to a clinic.

Medications and pharmacies

  1. Compare costs for drugs just like you do (or should) for everything else.
  2. Use generic drugs whenever possible. Also, patents for brand name drugs expire and generics appear all the time. Watch for when your medications will become available as generics and switch as soon as you can. Finally, many generics cost less if you pay for them yourself rather than paying the copay and charging insurance. Some drug stores charge $4 for a 30 day supply of generics, while the copay alone might be $10 if you used insurance.
  3. Use therapeutic equivalent drugs, those with the same effects but lower costs, whenever possible.
  4. Use preferred pharmacies in your network, or order prescriptions through the mail.
  5. If your doctor agrees, cut your pills. If you can get a prescription for twice the strength and half the quantity, you can save money.
  6. Know the rules that your insurance company has in place for prescriptions. Some insurance companies require that for certain conditions, drug A must be tried before drug B. If your doctor doesn’t know this and prescribes drug B, you may pay an unnecessarily high price.
  7. Get prescriptions for expensive over the counter drugs. That way you may be able to get reimbursed from your health savings account and get a tax advantage.
  8. For people with rare or severe medical problems such as pulmonary hypertension and some types of cancer, special drug programs can help defray part or even all of the medication costs.

Preventive Care

  1. Get your preventive care with no out of pocket costs. Insurers must provide such programs under the Affordable Care Act.
  2. When a doctor orders a test at a preventive care visit, make sure that the test is covered under such a visit by your insurer.
  3. Large employers often have wellness programs that pay cash or provide reduced insurance premiums for employees that meet certain health goals like losing weight or stopping smoking. Participate in these programs whenever available.

Medical insurance

  1. Compare costs when buying health insurance and get only what you need. Be sure to consider your kids health needs, because they can stay on your policy until age 26. Research fair prices for the coverage that you need and comparison shop.
  2. Change to a high deductible policy, and make sure you get credit towards your deductible for all your care. Even if you pay for something out of pocket, file a claim so you get the rate negotiated by your insurer. Schedule procedures towards the end of your deductible year, and do so ahead of time so you can get them when you want them.
  3. If eligible, get a health savings account (HSA) with the highest contribution limit allowable. If possible, get contributions from their employer as part of your employee benefits. You can also save in your tax bill by making a one-time roll over from an individual retirement account (IRA) to an HSA. You can’t contribute to an HSA after signing up for Medicare, but you can use the money for deductibles, co-payments, vision and dental care, and long term care. Finally, if you are self-employed you can deduct health insurance premiums from your taxes.
  4. Negotiating care – Ask your doctor’s office for a discount if you pay cash. If your insurance company denies a test or procedure, reconfirm the need with your doctor and then appeal it. Also ask for an itemized bill when you are hospitalized and watch for common billing errors,

Conclusion

For the past two hundred years, people in Western nations have expected someone else, usually their government, to provide medical care for them. This has never worked well, and is working less as time passes. Health is never perfect, and death still happens, but the real key to having the best possible health lies first with the individual, then with the family, then with the church and community, and lastly with government. Each person is ultimately responsible for him or herself, but by doing what is listed above, we can all have our best possible health.

Medical Preparation for Humanitarian Missions

“Doctor, this will be a very long war if for every division I have facing the enemy, I must count on a second division in hospital with malaria and a third division convalescing from this debilitating disease.” General Douglas MacArthur to Colonel Paul F. Russell, US Army malaria consultant, May 1943.

Just like soldiers going to war, people on humanitarian missions anywhere in the world can fail to accomplish their mission due to illness or injury. Whether missionaries seeking to advance the gospel of Christ, secular humanitarians trying to dig a well and build a school in a rural African village, or a combination of both, medical problems can inactivate the best intentioned and most capable teams. This article is intended to help people medically prepare themselves to go overseas on humanitarian missions. You can also watch the video.

Your baseline health

While in college I attended a lecture about living overseas doing humanitarian and missions work. The talk was fascinating but what changed my attitude was when the speaker said “to be most effective you must be in good physical condition. It does little good being an expert in your field or having the highest hopes when you physically are unable to perform.” That very day I took up running and in the 30 years since have never stopped. The basic three components of good physical health are adequate sleep (7-9 hours per night), good nutrition, and plenty of exercise. Meals should be high in fruits and vegetables, moderate in dairy, grains, and nuts, and low in meats and sweets. Exercise has three components: flexibility training six days per week, aerobic exercise at least three days per week, and resistance exercise at least two days per week, totaling at least 150 minutes of exercise per week. 10,000 steps per day is a common benchmark for walkers. Someone who is unfit at home will not become magically fit overseas; they are more likely to become even more unfit.

Living conditions will not be as comfortable on mission as they are at home. Water in developing countries is often contaminated, and ice is contaminated and scarce. Air conditioning is unheard of in much of the world, and the neediest countries are frequently the hottest. Showers, laundry, and good toilet facilities are usually harder to find in the developing world, Transportation may be lacking or dangerous, and garbage is often ubiquitous. Expect to walk farther and work harder on humanitarian trips than you do at home. Conditions that would be a minor annoyance back home can be harder to overcome. Overall, be in the best possible health before you go on mission.

Your pre-trip medical evaluation

Having practiced medicine for over two decades, I have evaluated many people preparing to travel overseas for business or pleasure. Such a visit is vital for medical preparation because it accomplishes a lot:

  1. Getting travelers up to date on their standard (US) required vaccinations.
  2. Giving travelers the vaccinations that are required for their destination, considering the conditions they are likely to face. For example, a person shopping in Tokyo for a week is not likely to need the vaccine against Japanese Encephalitis virus (JEV), but someone on a humanitarian mission for six weeks in rural Vietnam definitely needs it.
  3. Giving travelers the prophylactic medications, such as antimalarials and antidiarrheals, that are required.
  4. Refilling key prescriptions that travelers need to manage their baseline health problems, such as blood pressure or diabetes medications.
  5. Counseling the traveler on risks common to their destination, including identifying what they plan to do and figuring out how to minimize the health risks they face if they do it. This can range from teaching people about mosquito protection (bed nets, DEET and permethrin) to giving them information on local medical facilities in case they have trouble.
  6. Discussing what to bring on the trip.
  7. Discussing what to do on return from the trip, and when to come in again.

Visit your doctor at least four weeks before you leave for this evaluation. The Center for Disease Control and Prevention (CDC) provides useful information at their Traveler’s Health website. It is a good idea to visit the dentist before going since dental problems can be big and care may not be available. Patients with glasses may wish to get an updated prescription if they haven’t had one in the past year.

Insurance and Other Concerns

Most people going on humanitarian journeys will have medical insurance of some type, but you need to check the terms carefully. What benefits are available overseas? Is medical evacuation included? Do they require preapproval for visits, and is that possible at your destination? Will you need supplementary medical insurance? Trip interruption and cancelation insurance are also important. Such insurance can cost less than $10 per day.

The US State Department offers the Smart Traveler Enrollment Program (STEP). This free program allows US citizens and nationals to register their trip with the local embassy or consulate. The embassy will provide enrollees information about safety conditions in their destination countries, contact them in case of emergency, and provide a conduit for family and friends to get in touch if trouble strikes. Travelers who don’t mind the US government knowing about their trip may benefit.

The US Customs and Border Protection offers the Global Entry Program, in which pre-approved, low risk travelers get expedited clearance into the United States. The application process includes an online application, an interview, and a fee.

Your health packing list

Travelers on humanitarian trips must take the things that they need to stay healthy at home. These include:

  1. Enough prescription medications to last for the entire trip and two weeks afterward. These must be in their original containers and with original markings or they may be confiscated.
  2. One pair of glasses and one spare, or one pair of contact lenses and one spare pair of glasses.
  3. Other personal stuff such as extra batteries for a hearing aid, knee or ankle braces.
  4. Hand sanitizer, sunscreen and insect repellent.
  5. Ear plugs, since developing nations can be noisy, especially in vehicles.
  6. A pillow or neck pillow to improve sleep on planes and other vehicles and if you will be in primitive lodging.
  7. Eye covers (sleep masks) to improve sleep.
  8. Hygienic wipes to clean up when showers, or even water, are not available.
  9. Over the counter medicines – motion sickness, pain medications such as Tylenol and Motrin, decongestants, antacids, etc.
  10. If going on a medical missions trip, be sure to take personal protective equipment (PPE). This includes gloves and goggles in case you will be exposed to body fluids. For more serious risks of infection, such as responding to the current ebola outbreak, gowns and masks, or even face shields, are required. Gloves must be disposable, and everything else should at least be laundered daily after contact with patients. Adequate PPE may not be available at your destination.
  11. A basic first aid kit, including Bandaids for small wounds.
  12. Health documents such as copies of prescriptions, health insurance documents, and a contact card in case you are debilitated and colleagues need to reach the US Embassy or Consulate and someone back home.

Individual travelers will have other needs. Some may need a cane for walking, while others may need a back support to minimize their pain. Diabetics may need needles and syringes to self-treat their diabetes, and asthmatics may need inhalers. Again, people should take whatever they need to function at home, and a few other things tailored to the risks at their destination.

Healthy traveling

People going to places with poor toilet facilities often don’t drink enough clean water because they can’t find it, it is unappetizing (often warm), or they don’t want to use the toilet. This fact makes it even more important to be well hydrated (clear urine) before the trip. During the flight (or long drive), take off your shoes and stretch your feet and ankles. Stand and walk whenever you can, and sleep whenever you can, keeping a jacket or blanket nearby because planes can get cold. Keep medications, a change of clothes and raingear handy in case your luggage is lost.

Staying healthy on site

Drinking bottled water is important in all but the most developed countries, as is frequent hand washing, and using sunscreen and insect repellent. Missionary teams will likely be working with long term field workers and native staff and should take their cues from them. Non-faith based humanitarian teams should also have local support. I have seen troops in Iraq develop diarrheal disease from ice or even water on plates or soda cans so travelers must be careful. Motor vehicle accidents are the number one cause of death among travelers in the developing world and it is OK to ask local drivers to slow down.

Dietary suggestions are harder to give. The official recommendation is to eat only cooked foods and avoid salads or fresh vegetables. These recommendations are sound and can be followed by casual travelers but are harder in a missions context. Teams will often be invited into the homes of those they are working with and as such will be offered local food. As unappetizing as the food may look, it is probably the best that the host family has, and as such it would be a grave offense to reject it. There are no easy answers here, but eating small portions (never a bad plan) and staying with the food most thoroughly cooked is helpful. If you develop symptoms and make a return visit to your doctor after your trip, be sure to tell him about things like this.

Jet lag

The body operates on circadian rhythms which impact everything from hours of sleep to hormone levels. These rhythms are inherent and are influenced by light, drugs and other factors. Symptoms of jet lag include fatigue, slow mental processes, and poor sleep. Since most people don’t get enough sleep and have a baseline sleep deficit, they can minimize symptoms by getting as much sleep as possible before and during the trip. Once you are in the new time zone, stick as closely as possible to the new schedule, limiting yourself to no more than one nap of up to two hours duration per day.

Culture shock

When travelers first arrive in a new place they are often enamored by its newness. This “honeymoon” stage lasts up to a few weeks, by which time most casual travelers have returned home. Soon however, travelers who stay longer, as missionaries and humanitarian workers often do, start to dislike much of what they recently found so quaint, and they want to go home. Effectiveness plunges. Eventually they become acclimatized to the new culture just as they do to the new climate. Their function will improve and they will return to a new baseline. Culture shock happens when returning home as well.

Safety

Part of providing successful humanitarian aid is keeping team members safe. We have discussed medical issues and important threats such as motor vehicle accidents, but there are other things to keep in mind.

  1. Make copies of all travel documents, including passport, visa, plane tickets, and insurance. Keep a copy on the trip and leave a copy at home.
  2. Get good medical insurance, including evacuation insurance.
  3. Keep your passport and identification with you at all times.
  4. Avoid drawing attention to yourself, either with obnoxious behavior, ostentatious displays of wealth or immodest clothing. Avoid alcohol and drugs. You are there to serve others, not to display yourself.
  5. Do not walk or travel alone. Go in teams of at least two.
  6. Be sensitive to others and to the local culture.
  7. Do not identify yourself with issues likely to be controversial. Don’t wear obviously American or military clothing, or anything that may cause offense locally.
  8. Do not violate the trust or the security of the long term staff you are working with.

Team Leaders

It is your job to make sure that every member of your team is as ready as they can be. Consider an example from World War II:

“Good doctors are useless without good discipline. More than half the battle against disease is fought not by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine is taken, that shorts are never worn, that shirts are put on and sleeves turned down before sunset… I therefore had surprise checks of whole units, every man being examined. If the overall result was less than 95% positive, I sacked the commanding officer. I only had to sack three; by then the rest had got my meaning.” General Slim, Burma Campaign, WW II (under General Slim, the malaria rate in troops decreased from 12/1000 per day to 1/1000 per day.

While team leaders in missionary and humanitarian endeavors do not have the same control over their teams as generals during war, the principles still apply. Leaders must do everything possible to help those working with them to succeed in whatever mission they face. The ultimate responsibility remains with the individual, but the leader has a vital role to play. Make sure that everyone knows what your team’s mission is, and that your team members have the right equipment and supplies to accomplish that mission.

Leaders should ensure that a first aid kit is available for the team. This should include larger quantities of medication and supplies than individuals are likely to bring.

  1. Over the counter (OTC) pain medications such as aspirin, acetaminophen and ibuprofen – at least 100 tablets of each
  2. OTC diarrhea medications such as Imodium.
  3. OTC motion sickness medications such as meclizine.
  4. Three and four inch elastic (ACE) wraps to wrap injured knees, ankles, wrists, and elbows. Be sure that someone knows how to use them.
  5. A large box of Band-Aids.
  6. Extra water bottles with water filter and purification tablets (if in a remote location).
  7. Large bottles of sunscreen and insect repellant.

Conclusion

It may seem that there is too much to do. It may seem like much of this preparation is not necessary. Both statements are false. First, humanitarian and missions work is vital, there are so many people with so much need that people who can should go. Second, every part of the preparation noted above must be done. To do otherwise is to compromise the effectiveness of each individual, and each team, in doing this important work.

For more information, please look at the section “Personal and Team Preparation for Humanitarian Response” under the Virtual Emergency Operations Center at MDHarrisMD.com.

Discovery and Innovation in the Business of Health Care

Discovering things previously unknown is one of the most important, and most enjoyable, things that anyone can do. Most people do it every day, whether as simple as finding a new restaurant they love or discovering a new comet in the heavens. Fundamentally, new discoveries come from observation, analysis, and experimentation. A husband looking for a new restaurant to try with his wife might observe something that in his experience resembles a restaurant on a street corner. He then analyzes the available information to decide if he wants to try it; what kind of food they, the opening hours, and whether it is clean and inviting. Finally he and his wife try it out, completing the process of discovery.

New discoveries are often far more difficult than finding a great new place to eat. Identifying a new comet can require expensive equipment and uncommon expertise, while sequencing the human genome, learning about subatomic particles or curing cancer are some of the slowest and most resource intensive discoveries of all. The discovery that smoking causes lung cancer followed the same observation-analysis-experimentation sequence. In the 1930s a few surgeons noticed that they seemed to be performing lung cancer surgeries on a lot of smokers. Some published their observations and that induced others to analyze the existing information and hypothesize that smoking is associated with lung cancer. Researchers then developed experiments to test the hypothesis and in 1956 the British Doctors Study provided the first convincing evidence that smoking increased the risk of lung cancer.

Service industries such as health care use quantitative and qualitative methods to make new discoveries to improve the services that they provide to their customers. As a natural science, medicine makes new discoveries using a vast array of natural science methods such as laboratory and imaging techniques. As a social science, medicine also uses surveys, focus groups, and other techniques to gain information on people and their behavior.  As a business, medicine uses social science and other techniques to continuously improve its services to its stakeholders; including patients, family, staff, and others.

This article hopes to cover some of the methods that organizations, especially medical, can use to make new discoveries. In so doing, health care professionals can find the right questions and the right techniques to answer these questions for the benefit of their patients and others. 

Benchmarking

Regardless of the type of organization, benchmarking processes and outcomes against peers is useful. Manufacturers might reverse engineer a competitor’s product to improve their own and service companies might review the literature or even use secret shoppers to find best practices in their field that they can modify and imitate. 

Quantitative Methods

Since Frederick Taylor’s Principles of Scientific Management (1911), quantitative assessment of problems in business has been the standard. This should not be surprising, since Taylor’s key ideological tenets held sway over business thinking for much of the 20th century.

1.    The primary, if not the only, goal of human behavior and thought is efficiency.

2.    Technical calculation is in all respects superior to human judgment.

3.    Human judgment cannot be trusted because it is plagued by laxity, ambiguity and unnecessary complexity.

4.    Subjectivity is an obstacle to clear thinking.

5.    What cannot be measured either does not exist or is of no value.

6.    The affairs of citizens are best guided and conducted by experts.

Quantitative methods of making new discoveries have led to great advances in business and health care. Excluding bench and other basic research, these methods generally involve large numbers, both large numbers of subjects and large numbers of data points. They tend to involve standardized instruments to evaluate characteristics of their subjects, whether monitors to measure blood pressure or surveys to measure opinions.

Timing Categories of Quantitative Studies

Examples of Quantitative Studies

Prospective

Cohort – select a risk or protective factor and compare exposed with unexposed to see what outcomes they will develop.

 

 

Clinical Trial – select an intervention and compare exposed with unexposed to see what outcome they will develop.

Retrospective

Retrospective Cohort – select a risk or protective factor and compare exposed with unexposed to see what outcomes they have developed.

 

 

Case Control – select an outcome and look back in time (survey or other measurement device) to see what they were exposed to

Current

Cross-Sectional (prevalence) – examine risk or protective factors and outcomes that subjects have now.

Such quantitative methods are widely used in medicine and even in business. Data can be collected by instruments such as blood pressure monitors or laboratory equipment depending upon the object of the study. Data can also be collected by standardized surveys when investigators want to discover personal opinions or experiences. When done properly they provide valuable information which can be generalized beyond the study group to the larger population.

Qualitative Methods

These methods often involve much smaller numbers of subjects but provide much deeper insight into the needs and opinions of a small group or each subject. Focus groups, clusters of subjects specially selected by the researchers and working together, can provide qualitative data. Commonly used in business and politics, focus groups get individual responses which are conditioned by the group. 

Individual interviews are not guided by standardized surveys with preselected responses, such as “strongly agree – agree – neutral – disagree – strongly disagree” as is found in the Likert scale. Rather, while covering standard topics, they encourage group or individual stories from the subjects which pertain to the question at hand.

Design Thinking Process

A currently popular way of getting information, especially the qualitative component, is the Design Thinking Process (DTP). While qualitative methods often try to eliminate or minimize the subjective element in problem solving, design thinking attempts to “combine empathy for the context of a problem, creativity in the generation of insights and solutions, and rationality to analyze and fit solutions to the context (http://en.wikipedia.org/wiki/Design_thinking).”

Rather than dozens or even thousands of subjects, DTP typically recruits 10-12 subjects specially selected for some characteristics of interest to the researchers. They find the subjects through social media mapping, identifying frequent users of services, or asking key staff to recommend specific users. Simultaneously investigators try to ensure a representative demographic mix. In a hospital emergency department (ED), for example, study personnel might identify key opinion leaders who write about that ED and its services in Facebook, Twitter, or a blog. They might also examine hospital records to see which people used it the most and ask ED staff to recommend patients for the study.

After potential subjects are identified they have to be screened to decide who to include. A key determiner is who has the biggest potential influence to improve patient and system outcomes. Subjects must commit not only to providing data but also to help develop solutions.

Once researchers have a suitable number of the right volunteers, data gathering – individual interviews of each subject – begins. The first step is to develop a “journey map” for each subject. For a study to improve ED services in a community hospital, the map may begin when the patient first developed the symptoms that led them to the ED. They may be asked questions like this:

1.    Where and when did you first think that you might need to seek care? Why did you decide to go, and how did you get there? Please describe in detail what happened and how you felt.

2.    Who did you interact with at each location in the process? At home with family? With the EMS personnel? In the ED?

3.    What touch points did you have with the medical system? How was your interaction with each?

4.    What is your impression of the areas that you encountered? It is useful at this point to show patients pictures of pertinent locations, such as ED exam rooms, waiting rooms or front desks. These key areas color peoples’ opinions of everything and everyone else in the process.

5.    What could you see, hear, smell, feel, or even taste at each area? Was the environment hot, cold, too dark, too bright, too noisy, or something else?

6.    Were you given educational information? If so, was it useful? Why?

7.    What did you experience that was unexpected?

8.    Did you experience negative emotions? Which ones? Why?

9.    Did you experience positive emotions? Which ones? Why?

10.Was your experience seamless or fragmented?

Journey maps may begin even earlier. The first interaction that one person has with another or that a person has with an organization may be the expectation that one has of the other. Stakeholders may know, or think they know, well known people and organizations simply from their reputations. Therefore it is incumbent on everyone to consider how to improve others’ expectations of them, not just the physical interactions.

Journey maps also end later than the final physical interaction between people and organizations because of memory. A patient may have a wonderful experience in a hospital overall but have one truly bad interaction at discharge. That person’s memory of terrific care will be tainted and maybe even superseded by that last memory. Since memories of prior experiences color future expectations, people and organizations must manage them if they hope to please their stakeholders. The time-based process of interactions can be described like this:

Expectation

Does the customer or other stakeholder have expectations of the person or organization? If so, what are they, and how can they be improved?

First Impression

What does the customer or other stakeholder encounter the first time they make physical contact with services?

Discovery

Assuming the customer or other stakeholder stays with the person or organization, both parties begin to discover what the other is really like. Expectations and first impressions give way to lasting experience.

Usage

Assuming that discovery is satisfactory to all involved, they begin working together to accomplish mutual goals.

Memory

Eventually the interaction, whether an episode of care or something else, is finished. All parties remember their interactions, for good or for ill, and these memories shape future expectations.

Interactions between stakeholders and organizations do not occur only in time but also in space, and journey mapping also discovers these interactions. Some interactions happen directly to a stakeholder, such as a patient having surgery. Other interactions happen to their family or friends, such as a desk clerk being kind, or rude, to visitors trying to see the patient after surgery. Still other interactions happen in the public sphere, such as when a stakeholder sees a news story or an advertisement about a hospital. Innovators can find valuable clues on how to improve a customer’s (or a patient’s) experience by considering both time and space in their interactions with the organization.

For ongoing interactions between an individual and an organization, having the customer (patient) keep a week long journal of her interactions with the organization is useful. It is important to interview the subject in her context, such as home or work, to get the most insightful answers. Once each person has described their journey, researchers will begin to identify commonalities between them on the journey maps. They should use those commonalities to make a journey map of the subjects, which is called the Experience Map.

Simultaneous with gathering information from customers, known as patients in the health care setting, investigators begin selecting key organizational actors to participate. These may be doctors, nurses, and health care administrators, and their task is to join with the patients and solve the problems identified. First they write a blueprint of how the current service is designed. The blueprint helps match the front end experiences that the patient sees with the back end processes that the providers do. In the ED example, these staff members would carefully outline the current processes for screening and treating patients, as well as other pertinent processes. They would also identify principles that need to guide their thinking. For example, interactions with patients and other staff must be pleasant while at the same time being meaningful. “Pleasant and Meaningful Interactions in the ED” then becomes a key principle, known as an “Experience Pillar”, in the process.

Solving the Problem

The data gathering process is iterative; new data will constantly appear and be integrated into thinking on the research question and hypothesis. The solution process is also iterative; new data will modify the proposed solution and suggest improvements. Just as customers and staff are integrated into the data collection efforts, so customers and staff should be integrated into the problem solving efforts. The team that does this is the Co-Creation Team.

Looking at the service blueprint and the experience map, the Co-Creation Team uses Ideation sessions to look at the problems and at ways to fix them. They identify many possible solutions, but especially those that are small scale, low cost, and can be implemented quickly. The team presents its recommendation to decision makers and if all goes well their ideas are piloted. The easiest and quickest approach to the pilot project is to begin with the minimum viable solution tested in the minimum viable service. For example, rather than piloting a new mobile phone application to help patients coordinate their care with hundreds of patients in many different clinics and diagnostic categories, organizations can pilot a small version with a few dozen patients in one clinic in one diagnostic category.  In the National Capital Region, our pilot will involve a few dozen amputees in the Wounded Warrior clinic.

How to Optimize Discovery

Benchmarking, quantitative and qualitative methods are not contradictory but complementary in discovering how to best make a widget, provide a service, or care for a patient. In general terms, quantitative research and benchmarking can identify what is happening and where, while qualitative research can show how it is happening and why.

Conclusion

In a world of constant change, individuals and organizations must continually improve. To do this we must think differently, constantly making new discoveries. Using benchmarking, quantitative and qualitative methods provides a good means to do that.

Advent Tree Family Devotions – December 10

Wheat

John 6:31‑58; Matthew 26:26‑29

Since antiquity, wheat has been the most important grain in the world.  China, traditionally considered a rice-eating country, annually consumes 190 lbs per capita of wheat, mostly in noodles.  Each person in the US consumes about 144 lbs per year.  Wheat is even more important in the Middle East, with annual per capita consumption in Israel of 294 lbs and Egypt of 384 lbs.  Wheat is mentioned 52 times in the Bible, and Palestine was a major exporter in ancient times.  Grains such as wheat and rice contain carbohydrates which comprise about 55% percent of a healthy diet.

Jesus taught that man cannot live by (physical) bread alone and said “I am the bread of life”.   Just as physical bread is required for physical life, so spiritual bread, Jesus Christ, is required for eternal life.  In a powerful but frightening statement, He said that unless people eat His flesh and drink His blood, they cannot have eternal life.  Unless we take Jesus’ teachings into our hearts and minds, accept His sacrifice for our sins, and welcome His Holy Spirit into our lives, we cannot have eternal life. 

During the last meal of Jesus’ life, He broke bread and gave it to His disciples to eat, representing His body to be broken by the Crucifixion, just a few hours away.  He then gave them wine, representing His blood to be poured out for their sins.   Earlier in His ministry Jesus taught these men that they needed to let His Spirit reign in them, and in this final hour, He symbolically helped them do so. 

During the Holy Communion, the remembrance of this night, Christians take bread and wine to remember the Lord, and His great sacrifice for us.  Whatever our specific tradition in the Christian faith, this remembrance is a chance to reconnect with His Spirit, and be made more like Him.  But every day, whether Communion or Advent or not, we can thank God for His bountiful blessings.  

As with the other decorations, wheat is a common element in our lives.  Whether we are enjoying bread, noodles, pastries, cereals, or thousands of other food products using wheat, let us remember how Christ is the Bread of Life.  If we eat heartily of His body, our joy in Christmas will be renewed.  If we drink deeply of His blood, our peace in this busy time will be restored.  If we pause and remember vividly His sacrifice, our wonder at the mystery of salvation will grow, and our awe and delight and His unfailing grace will abound. 

Let us slow down and take time to come to Jesus for the bread and wine which sustains us through every trial and tribulation, gives us sustenance and encourages us to grow for Him. 

Are US Military Members Today Weaker Than in the Past?

On a recent speaking trip I was asked if cultural changes in the US military had emasculated it compared to the past. This is a daunting question, but like all questions, the first step in answering it is to define one’s terms. Aside from the anatomic definition, a reasonable definition of emasculation is “to deprive of strength or vigor, to weaken.”

In 2009 the Chairman of the Joint Chiefs of Staff, the highest ranking member of the US military, called experts in various fields together to try to identify all of the components of fitness, collectively termed Total Force Fitness (TFF). His goal was to improve all aspects of fitness in US military members. After long deliberation and study, the group identified the following areas:

1. Physical fitness – strength, endurance, flexibility, mobility
2. Environmental fitness – heat/cold, altitude, noise, air quality
3. Medical fitness – access to care, immunizations, screening, prophylaxis, and dental
4. Social fitness – social support, task cohesion, social cohesion
5. Behavioral fitness – substance abuse, hygiene, risk mitigation
6. Psychological fitness – coping, awareness, beliefs/appraisals, decision making, engagement
7. Nutritional fitness – food quality, nutrient requirements, supplement use, food choices
8. Spiritual fitness – service values, positive beliefs, meaning making, ethical leadership, accommodate diversity

As defined above the TFF is a new construct. Lack of data using this construct, both past and present, make it impossible to state definitively whether US military members are less fit today than they were in the past. However since the question was asked, and is being asked by many in American society, it is reasonable to provide a reasoned answer.

Physical, Environmental, Medical and Nutritional Fitness

On average, Americans going into the military are physically weaker today than they were in the late 80s and before, largely due to our increasingly sedentary lifestyles. Boys used to play outside every day but now many stay inside watching television, playing video games, and surfing the web. Children used to ride bikes or walk to school, but now many more are driven. The explosive growth of sports participation in the past twenty years deceives us into thinking that we are more physically fit than in years past. The obesity epidemic, even among the young, suggests that we are not. A Pentagon report in 2009 stated that 75% of Americans aged 17-24 are unfit for military service, almost half of those (about 35%) because of medical issues including poor physical condition (http://www.missionreadiness.org/2009/ready_willing/). Of draftees in World War 1, 20.6% were rejected for medical reasons (http://history.amedd.army.mil/booksdocs/wwii/NeuropsychiatryinWWIIVolI/appendixa.htm). Since some of those rejected for military service in WW1 had medical issues which are now easily treatable, we would expect that number to have declined dramatically, not risen by 50%.

The military is doing a better job of helping recruits get through basic training. Some may attribute it to better training but others attribute it to easier physical standards.

Service 1998 rate Latest Available Rate (2006)
Army 17.9% 13.6%
Air Force 8.8% 7.1%
Navy 17.0% 14.0%
Marines 13.5% 11.7%
http://usmilitary.about.com/od/joiningthemilitary/l/blbasicattrit.htm

Science’s knowledge of medicine, human performance, public health, and nutrition has grown, thereby improving physical, environmental, medical and nutritional fitness. Many acute and chronic diseases are more manageable today than previously and thereby impact warriors less than before. Smoking among military members has declined; another positive factor. More and better immunizations are available and levels are higher. The same is true for disease prophylaxis, access to health care and dental treatments. Air quality in America has improved since the 1960s, noise is better controlled, and heat/cold injuries are more preventable. All of these improve warriors’ physical, environmental, medical and nutritional fitness.

The answer to the question of whether warriors today are more physically, environmentally, medically and nutritionally fit than in eras past turns on whether the positive factors noted above offset the negative factors of poor nutrition and a sedentary lifestyle. It seems clear that Americans going into the military are less physically and nutritionally fit than in the past. It also seems clear that uniformed service makes people more physically, environmentally, nutritionally and medically fit.

Spiritual, Behavioral, Social and Psychological Fitness

The modern US military is better educated and makes greater use of technology than the US military of bygone days. Since all military members are required to be high school graduates, they are probably more educated overall than their forebears from the World Wars, Korea and Vietnam.

Besides education, the data on spiritual, behavioral, social and psychological fitness are also mixed. Rates of divorce and depression have skyrocketed since the 1970s, while rates of drug and alcohol abuse in the military have plummeted. In part this reflects pre-entry selection; people with a history of alcohol or drug use are not allowed into the military. It also reflects a no-tolerance attitude for drug abuse in the military. Acceptance of diversity, improvement of hygiene, and risk mitigation, other aspects of fitness, seem to have improved. Ominously, the single greatest indicator of a lack of spiritual, behavioral, social and psychological fitness, completed suicides, has worsened.

The TFF paradigm does not specify adherence to a certain religion as evidence of strength or weakness but rather specifies traits that are associated with better fitness in these areas. Medical and social research, however, cannot speak in such generalities. Studies must be done on specific individuals and ask specific questions. In the United States the vast majority of research done on the influence of religion on health looks at Christianity. It is to these data that we must direct our questions on spiritual, behavioral, social and psychological fitness.

The percentage of self-identified Christians in the US is declining, and military members are less likely to self-identify as Christian than the general public. Judaism has also declined. Islam, Hinduism, Buddhism and Sikhism have grown modestly, largely through immigration, but there is little data on their effects on the health of their adherents. Those who are “non-religious” in America are growing the most of all. Why is this important? Because a surfeit of research demonstrates that people who actively practice religion, usually defined by regular churchgoing, gain many health benefits:

1. Churchgoers are more likely to be married, less likely to be divorced or single, and more likely to be highly satisfied in marriage.

2. Religion helps poor people move out of poverty.

3. Regular religious attendance decreases rates of suicide, drug abuse, births out of wedlock, alcoholism, and crime.

4. Religious practice helps people stay off welfare.

5. Regular religious practice decreases rates of depression and improves self esteem.

6. Church attendance increases longetivity, improves recovery from illness, and decreases rates of many serious diseases.

7. Religious practice helps people recover from alcoholism, drug abuse, and other problems.

Of the studies on the effects of religion done through the mid 1990s, 81% showed a positive influence, 15% were neutral and 4% showed a negative influence. Intrinsic religion, religious practice which is genuine and focused on God, has positive effects. Extrinsic religion, religious practice done for show without genuine belief, has negative effects (http://www.heritage.org/research/reports/1996/01/bg1064nbsp-why-religion-matters). Studies since then have confirmed these findings.

It should be clear that these health benefits directly improve some of the characteristics noted in the US military-sanctioned TFF model. Insofar as modern military members are less religious they do not gain these benefits. Since their predecessors were generally more likely to self-describe as religious, they probably had better psychological, behavioral, social, and spiritual health than the soldiers, sailors, airmen and marines of today. Perhaps this partially explains the growing problems of joblessness, homelessness, and suicide among American veterans.

Conclusion

Answering the question “are US military members weaker today than in the past” is difficult. Rephrasing the question to “are US military members less fit than their predecessors” allows us to use the US military-approved Total Force Fitness paradigm to attempt an answer. Even so, the answer is not clear. We discover that in half of the areas, physical, environmental, medical and nutritional fitness, American service members who have completed initial training (and probably an initial tour of duty) are probably more fit than their predecessors. From a psychological, behavioral, social and spiritual perspective, the picture is less rosy.

Healing the Health Care Cost Conundrum

The military health care system is different in many ways from the civilian system, but a primary difference is the income incentive. Simply put, health care providers and other medical professionals are not paid based on the number of patients that they see or the number of procedures that they do. Instead they receive a fixed salary with few if any bonuses for productivity or quality. The budgets for military health care institutions, and many others in the Federal government, are based on Congressional appropriations, not on productivity. This has been changing in the past decade but remains largely true today.

Civilian medicine is not so. They are paid for what they did, patients seen and procedures done, and everyone on staff is usually highly motivated to do more. Some have described such fee-for-service reimbursement arrangements as “you eat what you kill.” In some practices, that can equate to more visits and more procedures, even if some are not medically required.

Each system has advantages and disadvantages. If medical personnel have no financial incentive to see more patients, they will generally see fewer. Since the fixed costs of health care are high the cost per patient will increase. Further, access to care may decrease if doctors see few patients per day. If medical personnel are paid by the patient seen and procedure done, they will generally see more, potentially improving access to care and decreasing the cost per patient. Unfortunately, they will also do more, including procedures with marginal benefit to the patient.

Some say that health care in the United States is poor, and they are wrong. While some population health metrics show that we have a long way to go, others show how far we have come. Most metrics of medical care demonstrate that we have the most advanced system in the world. Health care in the United States is good, but is very expensive. As these facts illustrate, finding the right balance in payment for health care in America is difficult. Nonetheless, there are some simple ways to reduce prices and control costs in US health care.

Require transparent pricing – Bitter Pill: Why Medical Bills are Killing Us was the cover story on the 20 February 2013 issue of Time magazine. It described frightening patient experiences with huge bills, inconsistency in pricing, and even duplicity. Though biased, the article raises some valid concerns. Just as pricing in other fields should be transparent to the consumer, so should pricing in health care.

Require transparent quality measures – It is difficult, but not impossible, to measure the quality of a health care institution or system. HEDIS and Oryx measures are commonly used and effective, as are readmission rates. Health care facilities could advertise and compete on their accreditation scores, such as Joint Commission. Consumers need quality measures in addition to transparent pricing to know where and when to spend their health care dollar.

Reform the Relative Value Scale Update Committee – Medicare and insurance payments are determined by a 31-member group that is dominated by specialists, with only one seat reserved for a primary-care doctor. Hence specialist payments are high and primary care payments are low. Primary care accounts for 51.3% of all visits to office based physicians in the US, while it has only 3% representation on this committee (http://www.ahrq.gov/research/pcwork1.htm).

Prescribe generic medications – Health care providers should use generic drugs whenever possible. They are regulated just as much as name brand drugs and are far cheaper. Generics tend to older drugs because of patent law and therefore have much more safety and efficacy data than newer drugs.

Make more medications and devices available over the counter (OTC) – self health care, often involving OTC medications and devices, can save a lot of money for American health care payers, including consumers. Widespread availability will drive costs down and quality up due to the forces of competition. Information on the proper use of these things is more available than ever before due to the Internet and computer applications. Pharmacists are usually available at point of purchase to answer questions and the health care providers are becoming more readily available via secure messaging over mobile devices for consultation. Devices themselves, such as Automatic External Defibrillators, have become smarter. Quality concerns are still valid but must be balanced against access to care concerns.

Engineer health, don’t just advocate it – Occupational health experts have long known that it is better to engineer out workplace hazards than it is to use administrative controls to prevent injury and illness. Sidewalks, bike lanes, traffic circles, parks, and other community improvements encourage active lifestyles and improve health. Seat belts, bike helmets, fluoridated water and immunizations are other examples. They are far more effective than administrative and advertising programs designed to encourage or force healthy behavior.

Reward good behavior – Payers such as employers and the government, should provide meaningful rewards for people who improve their health by stopping smoking, losing weight, and making other positive behavior changes. Reduced insurance premiums and health savings account benefits are two possible motivators. These rewards should not be given to those who do not improve their health in a measurable way. Ultimately the responsibility for the health of each person lies with that person, and those who are successful should be rewarded.

Encourage insurance competition – Nationwide competition between insurers, when paired with the other reforms mentioned here, would go far to control costs and still maintain reasonable levels of quality.

Enact tort reform – Like it or not, defensive medicine wastes money and can create a hostile environment between physicians and patients. Further, it limits providers’ ability and willingness to provide pro-bono or low cost care. Some patients are thereby denied care entirely, a bad outcome for everyone involved (except perhaps tort attorneys). While patients should be compensated for mistakes, limiting punitive damages introduces safeguards into the system which benefit everyone.

Take hospice seriously – Many patients with terminal diseases could benefit from home hospice care earlier after diagnosis. During the 1990s, 25% of health care costs were incurred in the last year of life (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464043/). Most people would prefer to die at home, but 56% die in hospitals and 19% in nursing homes (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282180/).

A health savings account (HSA) for everyone – Anytime that patients take a bigger role in their health care, everyone wins. Tax exempt and employer contribution HSAs help consumers get better health care, and better health, for their dollar.

Institute patient and family centered medical homes (PFCMH) – The concept behind PFCMH is that the patients and their families are the most important parts of the health care system. The medical team is responsible for the total health of patients enrolled to them and is rewarded for healthy patients rather than the number of visits or procedures. The data suggest that patients who receive care in the PFCMH context are healthier and happier, and costs are lower, than patients receiving care in other systems.

Practice evidenced based medicine – Medical research provides medical answers in terms of averages, such as how long a typical woman with breast cancer might survive. It cannot answer how long a particular individual with breast cancer will survive. Clinical practice guidelines (CPG) provide the best way to manage the “average” patient. Since most patients are, by definition, around average, CPGs are useful. It takes the individual acumen of the physician to determine how best to use the CPG for each individual patient. The Veteran’s Administration and the Department of Defense have made some excellent CPGs which can be found at http://www.healthquality.va.gov/.

Promote physical fitness

Physical exercise helps everyone at every stage of life. Whether a child on the ward or an elderly person in the intensive care unit, activity helps physical and mental health. Passively putting unconscious patients through the full range of motion in all of their joints improves strength, range of motion, and overall functionality. Having the patient actively do the same thing, unless contraindicated, is even better. Rehabilitation after surgery or injury and prehabiltation before make outcomes much better. There are few people on earth who wouldn’t benefit from more physical activity.

Avoid emergency departments except for genuine emergencies – Non-urgent or emergent care done in emergency rooms is more expensive and lower quality than that same care provided in a doctor’s office.

Encourage support of family and friends – many patients who have difficulty with activities of daily living need care in expensive skilled nursing facilities. Doing the same care at home with visiting home health nursing personnel is better for the patients and saves money.

Compete for patient dollars – Informed and engaged patients and families are the best defense against bad health outcomes and unclear or even exorbitant costs.

Conclusion

While some improvements in health care are complicated, others are simple. Making the improvements mentioned here would go far toward lowering costs and improving quality in American health care. Insofar as is germane to the military system, we are doing all of these. We cannot afford not to do them.

 

Using the Military Decision Making Process in Civilian Organizations

The vocabulary of the Military Decision Making Process (MDMP) is not typical for civilian organizations, but the concepts are germane.  Translating MDMP into health care can be very useful for process improvement.

Mission receipt – The commander provides the mission to his or her command. In a civilian setting, this would be the leader at any level.

Mission analysis – Identify explicit and implicit tasks

METT-TC – Mission, “Enemy” (forces opposing mission accomplishment), Troops (resources available to accomplish mission), Terrain (environmental factors affecting mission), Time, and Civil considerations (maximizing benefit and minimizing damage to peripherally involved parties)

Course of Action (COA) Development

Multiple courses of action required (at least three). Each COA must specify how that course of action will accomplish the mission (who, what, where, when).  The mission is the “why”. Always consider the following concepts in COA development:

1. Battlespace

To an Army planner, “close” operations means close to the forward line of troops, “deep” means behind enemy troops, and “rear” means behind his own troops. He must prepare to fight in all zones of battlespace.

In a marketing campaign, “close” operations might be marketing to your immediate customers and community.  “Deep” operations might be marketing your product to potential customers and communities nearby.  “Rear” operations might be marketing yourself to your employees and other internal stakeholders.

2. Center of Gravity

The center of gravity is the key difficulty underlying every problem.  In Operation Desert Storm, the centers of gravity of the Iraqi forces were the command and control network, the air defense network and the Republican Guard.  Allied forces destroyed these centers of gravity first, and Iraq was defeated.

In health care, one of the biggest problems is access to care, getting enough of the right kind of medical interventions to meet the demand.  Centers of gravity include leadership, and may include personnel, space, or some other factor, depending upon the situation.

3. Combined Operations

To an Army planner, combined operations means that forces in every element, land, sea, air, space and cyberspace, must engage to achieve the objective.  In a marketing campaign, “land” may be person to person, “air” may be radio and television, “sea” may be direct mail, and “cyberspace” is cyberspace.  Thinking about initiatives in terms of combined operations helps ensure that leaders don’t miss valuable opportunities to act.

COA Analysis – Analyze each COA for risks and benefits including cost, safety, etc.

COA Comparison – Use a decision matrix, comparing the advantages and disadvantages of each course of action. This includes a comparison of hazard probability (frequent, probable, occasional, remote, or improbable) with hazard severity (catastrophic, critical, marginal, negligible).

COA Approval – after a decision brief, the commander or other decision maker decides which course of action the organization will follow.

Orders Production – the headquarters staff produces the guidance document for the organization

Warning Order (WARNO)– indicates that an order is about to be issued

Operations Order (OPORD) – the main order

Fragmentary Order (FRAGO) – a partial order that provides additional information to the OPORD.  It may precede or follow it.

Civilian organizations, and especially health care, do not use “orders” in the military sense but nonetheless use documents for policy, instruction and direction. The military Orders paradigm provides a useful guide.

How to Pick Your Fitness Goals

For the past two weeks many Americans have enjoyed the Olympic Games.  Watching the fastest runners and swimmers, the finest gymnasts, and the best teams in the world is both an inspiration and a thrill.  It stirs the heart to see the athletic prowess that these young stars can reach.  So moved, many people commit to improve their own physical fitness and set goals to achieve that end.

To get fit, people need first to decide what their goals are.  The first goal is rehabilitation.  Injured athletes, and even injured couch potatoes who wish they were athletes, need to have healthy and normally functioning muscles, bones and nerves, not to mention organs such as heart and lungs, to be fit. How many of us sprain our ankle, strain our back, or bruise our muscles, and when the pain goes away think that we have fully rehabilitated?  Some people exercise despite having a bad cold, the stomach flu, or a headache.  You might say that the first goal in fitness is to move from abnormal health to normal health.

The second goal in fitness is to optimize health.  Many people have normally functioning bodies but still are not in good physical condition. The American College of Sports Medicine recommends 30 minutes of moderate cardiovascular exercise five days per week, resistance exercise two days per week, and flexibility exercises three days per week.  Such a routine will not produce Olympic champions, or even local tennis club champions, but will provide a good level of fitness for day to day life in most people.

The third goal in fitness is performance.  Long distance runners run 50 or more miles per week, in addition to other exercises, to be the best in their sport.  Swimmers, cyclists, gymnasts, and other athletes spend hours more practicing to perform at whatever level they need to be competitive.  To most military members, “performance” may be limited to successfully doing their jobs, keeping up on unit runs and passing physical fitness tests.  To competitive athletes, “performance” may mean practicing their sport 8 hours per day, five or six days per week.  Olympians may work at that intensity for decades.

Keep in mind that sometimes high performance impairs fitness.  Swimmers who specialize in the butterfly stroke and baseball pitchers can develop shoulder instability.  Long distance runners burn so many calories that if their food intake doesn’t increase enough, they can get muscle wasting and brittle bones.  One of the most important goals in sports medicine is to help athletes achieve their performance goals without compromising their overall fitness.

While you sit on the couch and watch sports after the Games, think about how to change your lifestyle to improve your personal fitness.  Do you have an ankle or knee that has never been quite right since that injury a few years back?  Get it checked out and get a personalized rehabilitation plan.  Are you pretty normal but just don’t get out and move?  Figure out how to change your schedule to make time for exercise and good fitness.  Then get with a friend and go for it. Do you want to be an Olympian, or at least champion of next month’s golf tournament at your local course?  Talk to a local trainer and sports medicine professional to get a personalized performance plan.

Fitness and prevention are two of the most important topics any of us can learn for our health.