Navigating Healthcare – Patient Safety and Personal Healthcare Management

May the Fourth be With You

It’s the artificial holiday that celebrates the play on words from Star Wars movies – a rallying cry

The list of suggested actions from the Starwars site may not be to everyone’s taste and includes everything from

  • Holding movie marathons
  • Dress up as a Star Wars Character
  • Star wars food including blue milk!
  • Getting a Star Wars Tattoo


But this year I follow Yoda’s advice:

“Pass on what you have learned”

Specialty Pharmacy

This year I attended the Asembia Specialty Pharmacy Summit held this time each year in Vegas at the Wynn/Encore resort. This is the largest conference for specialty pharmacy but as Alex Fine noted and I agreed –


All pharmacy is moving rapidly in the direction of specialty as we head into a world filled with precision medicine customized to the individual. On the one hand, this is an exciting proposition – at least to me. I am always reminded of the great scene in Monty Python’s Life of Brian

You are all individuals…..we are but medicine has not treated us that way. Historically the path to understanding disease was based on grouping patients, diseases, signs, and symptoms into logical groups that helped decode underlying cases of a disease.Just think of the seminal work of Louis Pasteur and Robert Koch who established the germ theory of disease and the resulting incredible advance in outcomes that derived from that block of work when Joseph Lister published in 1867 his Antiseptic Principle of the Practice of Surgery (met by substantial skepticism and took years to be widely accepted and adopted). This was just the start as we came to understand causative agents behind diseases that had vexed the profession. Treating someone with an infection with Penicillin thanks to Alexander Fleming’s work in 1928 was just one of many advances that grouped patients based on similarities of their disease. This methodology has served us well but the sequencing of the human genome- completed in Jun 2000 would have a big impact on this thinking.

Just think of the seminal work of Louis Pasteur and Robert Koch who established the germ theory of disease and the resulting incredible advance in outcomes that derived from that block of work when Joseph Lister published in 1867 his Antiseptic Principle of the Practice of Surgery (met by substantial skepticism and took years to be widely accepted and adopted).

This was just the start as we came to understand causative agents behind diseases that had vexed the profession. Treating someone with an infection with Penicillin thanks to Alexander Fleming’s work in 1928 was just one of many advances that grouped patients based on similarities of their disease. This methodology has served us well but the sequencing of the human genome- completed in Jun 2000 would have a big impact on this thinking.


Over the course of the last few years, we have seen a clear move towards the individualized understanding of patients and disease accompanied by the inclusion of patients (Patient Engagement).

Patient Engagement and Access

There was a clear theme in the messages from various presenters that offered a clear vision of the push towards the consumer and patient engagement and a clear desire to find a path to delivering access to everyone that was captured by Liz Barrett from Pfizer in her keynote presentation and summarized with her slide – The 4 Tenets for Healthcare:

Access to quality
Long-Term Value
Competitive principles

Providing access that overcomes the current challenges but builds in incentives for everyone in the system – not just the providers and hospitals but also patients and everyone involved in healthcare. This is the principle of competition without which systems tend to decline and ultimately stop working. There are people who perceive competition and capital principles as contraindicated in healthcare that we want to provide to everyone. I think these ideals can and should co-exist – without competition motivation disappears and efficiency will decline.

To achieve this we should take a book out of Yoda’s wisdom to pass on this wisdom and my key message for this day. Benefiting from the extended community. Our ability to connect and access people and resources has never been better. The need to remember data is much reduced:


This access goes far beyond the data and to people and resources. Can you imagine making a purchase without looking at ratings and reviews on sites – I can’t. Yet the reviews are from people I don’t know and have not met – yet I trust them. This works because of the human desire to help others (this, by the way, is the reason that social engineering as carried out by hackers is so successful – this will be the subject of a post coming up in the future). But this creates an incredible set of resources and talent available to you.

Patient Communities

Some of it is formalized like the early website entry in this area: Patients Like Me. But extends to informal interactions on social media channels like facebook and one of my favorite: Paying till it Hurts. Then there is your extended family and friends who all want to help. You will find people who have been through similar experiences, will have tips and ideas on how to deal with problems that others have faced and have conquered

I was lucky to hear Arnold Schwarzenegger present as the keynote at this recent conference – his recurring theme was that he was not a self-made man but his success was the result of all the help and support he received from others

So use the power of the Force – it is your network, your friends, family and those around you.

Derive strength from them, have them provide tips on what small changes you can make to improve your health and then help keep you on track – nothing like knowing that you are being watched to help keep you on track.

One of my most successful personal health drives was base don a weekly self-reported weigh in for myself and two colleagues. Anytime I felt I was going to make a poor choice on food or exercise I just thought of the weekly chart and where my line would be relative to my colleagues and I did not want to be the outlier.

Have you had success helping friends and family? What works and what doesn’t. Is there a special trick or insight you could share that might help someone else – share it now and help the community.


May the Fourth be With You was originally published on Dr Nick – The Incrementalist


Low Carb Diets – Good Or Bad

Posted in Nutrition by drnic on September 24, 2010

The fad of diets come and go like the tides in the ocean and he low carbohydrate (aka Atkins Diet) continue to resurface in different forms. For many these diets represent a roller coaster of weight loss followed by similar weight gain but a new study in the Annals of Internal Medicine Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet (PDF version here) demonstrated some surprising findings……

Both groups lost about 7% of their weight but what was surprising was the Low Carbohydrate diet had better cholesterol levels in their blood including an increase in the HDL (good cholesterol) all representative of factors that reduce heart risks.

Don’t celebrate too much yet though. Both groups had very intensive monitoring and support and this was probably as important if not more important to the success of the weight loss program. The results do seem to suggest a counter intuitive improvement in cholesterol levels despite a low carbohydrate diet that contained more fats.

Key learning point here – focus and support to improve compliance and adherence to weight loss and fitness programs is successful in achieving and maintaining weight loss

Would you like a statin with that Burger

Posted in DrVoice, Nutrition, Personal Health, Statin by drnic on August 16, 2010
Perhaps a better strategy might be not eating the burger and shake rather than offering packets of Statins to go with excess fat and food intake:
A Burger, Shake, and Some Statins
But practical challenges seem to prevent our ever increasingly over weight society from moderating input so this could prove to be a practical approach that works. You might even find food manufacturers and restaurant offering to add it to food for you. In some respects this is similar to the addition of the anti dote to overdose of acetaminophen (Tylenol) that is available and would prevent liver damage in the case of over dosage. But like this concept statins may suffer the same challenge – economics. While most recognize the value of extra safety of adding the antidote to Acetaminophen this version has limited sales as it costs more and cannot compete with cheaper version that don’t contain the antidote. Adding statins will likely be an economic issue not to mention the side effects that accompany statin therapy
Would you take food with statins for prevention?

Vitamin Water Comes up Lacking

Posted in Nutrition by drnic on June 29, 2010

It won’t come as as a surprise to some that the Vitamin Water fad is not delivering any real value. The Washington Post asked the question “How nutritious is Vitaminwater?” and came up empty. This stuff has been around since 1996 but it is only recently I have seen it permeating everywhere with kids asking for Vitamin Water vs plain old water.

The additives in this case are limited especially in the case of the “fruit punch” variety:

Vitaminwater tastes okay, if you like fruity flavor without the fruit. There is almost no actual fruit, even in the “Fruit Punch” variety, and what little there is mostly provides color

What’s in this masterful package – well for one a big hit in calories providing 125 calories in one bottle (just shy of a can of Coca-Cola! But with more focus on calories and excessive sugar intake sales have declined so the marketing machine has jumped into high gear and is now offering additional low calorie options. Seems like water fulfills that requirement and if you desire is to be healthy then take note of the Dietary guidelines:

The truth is that the research on supplementing with vitamins does not prove or show that people who take them are healthier than anyone else,” she explains. Indeed, the proposed Dietary Guidelines for Americans for 2010 explicitly say most people don’t need vitamin supplements

Better to eat healthy and consume fruits and vegetables to get the real things vs some artificial version that is likely inferior. Add to that the additive effect of fiber and phytonutrients that work together with the vitamins in real vegetables and fruits and you have a much better package all round

Exercise will Make you Fat – Not!

Posted in Healthcare Information, Nutrition by drnic on August 20, 2009

In some recent news Time Magazine headlined a piece titled: The Myth About Exercise” which suggested that exercise was fueling hunger and making people fatter. Complete and utter codswallop! But the fact that Time magazine gets away with this kind of piece and worse yet as was featured on one diet blog has people saying:

“If Time magazine dedicates an entire cover story to it then it must be big”

Is a very worrying result. They go on – “the question health researchers are now asking is “Is Exercise really needed for weight loss”

Good grief – who writes this stuff. Providing even a small element of hope for the already overweight population that is getting fatter and unhealthier is just plain wrong. You can see some great presentation of economic and health trends at GapMinder here (Presented at the equally great site of TED Talks by Hans Rosling).

Even if there is a shred of truth to any of the report we need to be encouraging exercise not discouraging it. Our population needs exercise – in fact your body needs exercise
Don’t loose site of this goal of regular and frequent exercise.

As Rebecca Scritchfield pointed out in her blog of this media disinformation is a big price we pay for listening to this tripe. As she says

the reality is the science tells a totally different story: There is strong evidence from the majority of the scientific literature that physical activity is an important component of an effective weight loss program; Physical activity is one of the most important behavioral factors in weight maintenance and improving long-term weight loss outcomes. In fact, participation in an exercise program has proven to be the very best predictor of maintaining weight that was lost; Effective weight loss and maintenance depend on a simple equation called energy balance: Calories expended through physical activity and normal lifestyle functions must exceed calories consumed; It is a myth that exercise can actually prevent weight loss by leading exercisers to overeat. Research and common sense disprove this notion. Look around the gym or the jogging trail. If this were the case, wouldn’t those who regularly exercise be the fattest?

Quite! Don’t get duped by the media’s desire for sensational shock stories. There is more on this blog with Good Morning America bringing on an “expert” nutritionist providing a platform to someone who as Rebecca points out”

ANYONE can call themselves a nutritionist. You can. Your grandma can. President Obama can.

So from this nutritionist I am here to tell you exercise is good and an essential part of a weight loss and positive health program. So get off your chair, turn off the computer and go for a will do you some good. Then Rinse lather and repeat!

The Fountain of Youth Available Now – Side Benefits Included

Posted in Genetics, Healthcare Information, Nutrition, Preventative Healthcare by drnic on July 9, 2009

It is no big surprise to see the results of a recent study of a long running study of primates that shows significant value in a low calorie diet. This article reported on MedPage here in July 2009. The headline here:

researchers have shown that restricting calories in primates maintains their youth and prevents age-related disease

Let me state that again:

researchers have shown that restricting calories in primates maintains their youth and prevents age-related disease

The research is exciting since this represents a real way to reduce disease and extend high quality life. Unfortunately the nature of society today makes for an interesting slant on this information and so the the researchers are interested in the possible short cut that this research might help develop:

open the door to drugs that would mimic so-called caloric restriction

Sigh…… much better to actually use the information to drive healthy behavior.

The effect has been know for many years in other animal models and a peak into other research papers reveals similar findings. The Annals of New York Academy of Sciences 25 Jan 2006: Caloric Restrictions in Primates demonstrated caloric restriction (CR – the fancy term for low calorie dieting) has significant benefits:

that reproducibly extends mean and maximal life span in short-lived mammalian species. This nutritional intervention also delays the onset, or slows the progression, of many age-related disease processes. The diverse effects of CR have been demonstrated many hundreds of times in laboratory rodents and other short-lived species, such as rotifers, water fleas, fish, spiders, and hamsters. Until recently, the effects of CR in longer-lived species, more closely related to humans, remained unknown. Long-term studies of aging in nonhuman primates undergoing CR have been underway at the National Institute on Aging (NIA) and the University of Wisconsin-Madison (UW) for over a decade. A number of reports from the NIA and UW colonies have shown that monkeys on CR exhibit nearly identical physiological responses as reported in laboratory rodents. Studies of various markers related to age-related diseases suggest that CR will prevent or delay the onset of cardiovascular disease, diabetes, and perhaps cancer, and preliminary data indicate that mortality due to these and other age-associated diseases may also be reduced in monkeys on CR, compared to controls

But the latest research linking this finding to human’s is more recent (though in all honesty is this surprising to anyone!). But the news is even more exciting. The low calorie group had some additional side effects:

  • Zero incidence of Diabetes in the CR group (compared to 30% in the other group)
  • A reduction in incidence of Cancer of 50% in the CR group
  • 50% reduction in Cardiovascular Disease in the CR Group

Do you need anymore incentive on healthy living? I know I don’t! Reduce your calories now – your body needs you to!
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The Food Industry – New Tobacco

Posted in Nutrition, Preventative Healthcare by drnic on June 23, 2009

Its a radical idea but a recent article in the NY Times (How Food Makers Captured Our Brains) lends some credence to the idea that the food industry is behaving much like the tobacco industry was some years back (and probably still today). They engineer their food and the contents to make it as addictive as possible. This is done with no regard to health or health consequences. Their desire is to hook us to their product making us want more. Dr Kessler (Pediatrician that has served two presidents in his role at the FDA) has recently published a book: The End of Overeating: Taking Control of the Insatiable American Appetite)

My original supposition that I have shared with others was centered on sugar as the key ingredient akin to Nicotine – addicting and the reason why my kids have always preferred <INSERT: name of Fast Food Chain> Hamburger when compared to a home cooked Hamburger. But it is likely more about the combination of foods that is achieving this level of addiction:

food companies certainly understand human behavior, taste preferences and desire. In fact, he offers descriptions of how restaurants and food makers manipulate ingredients to reach the aptly named “bliss point.” Foods that contain too little or too much sugar, fat or salt are either bland or overwhelming. But food scientists work hard to reach the precise point at which we derive the greatest pleasure from fat, sugar and salt. The result is that chain restaurants like Chili’s cook up “hyper-palatable food that requires little chewing and goes down easily

The Snickers bar, for instance, is “extraordinarily well engineered.” As we chew it, the sugar dissolves, the fat melts and the caramel traps the peanuts so the entire combination of flavors is blissfully experienced in the mouth at the same time.

As he points out much of this is not about will power but the daily challenge we face in the over stimulated world of food. Knowing your own triggers (good and bad) is a great place to start. I know my own personal bad trigger is in the evening…I’ve been good all day and want to sit back and unwind and have big urge to head for anything sweet. My strategy is to deflect to an alternative in my case some type of herbal tea. This works well int he winter but is not as easy in the hot summer months when hot tea is less attractive. As with many things this is a journey not a destination. Who knows someone might have a good suggestion for an alternative that suits me – let me know I’ll share any that I receive.

There are no quick fixes and we and our children face this challenge on a daily basis but understanding what is affecting us and developing coping mechanisms can be a great start.
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Exercise is just Part of the Answer

Posted in Healthcare Information, Nutrition, Preventative Healthcare by drnic on February 16, 2009

There is a lot of advice in the media suggesting that with just 20 – 30 minutes of exercise per day all your troubles will be over and everyone would move into the realms of healthy  living, with no long term disease issues……this feels a lot like the old Snake Oil problems in the wild west many years ago.

One size fits all – doesn’t

The difficulty with this and the problems of selling this message are covered in this NY Times article “Does Exercise Really Keep Us Healthy?” that points out that while 20 – 30 minutes of exercise does reduce diabetic risk and improve Osteoporosis (bone loss) it will not provide sustained weight loss or blood pressure reduction on its own.

To be clear – exercise has many benefits and changing from a sedentary lifestyle to an active one will help in *all* cases but it needs to be part of a complete program that includes weights and most importantly diet. The population in general east too much and if you have ever bothered to find out what your meals contain in the way fo calories you’d know for yourself. Calories are as a good an indicator as any and you’d be shocked at what’s in most fast foods especially when stacked up against what consumption level you should be at for your sex, age, and height. Even worse if you should be reducing this to effect some level of weight reduction.

The difficulty, Dr. Blair says, is that it’s much easier to eat 1,000 calories than to burn off 1,000 calories with exercise. As he relates, “An old football coach used to say, ‘I have all my assistants running five miles a day, but they eat 10 miles a day.

And there you have it – exercise and diet. It sounds simple but its not because if it were we would all be svelte specimens living into our 80’s with few health problems and the health bill for our nation would be a much smaller proportion than the current 16% of our GDP

Obesity Prevention – Why are we Failing

Posted in Healthcare Information, Nutrition, Preventative Healthcare by drnic on January 31, 2009

In one of the McKinsey interviews of 2008 with Toby Cosgrove CEO of the Cleveland clinic that focused on innovation item 1 in the list of things that need to be done he stated:

The first is prevention. The only thing we can do to reduce costs, while still improving quality, is to reduce the burden of disease. Forty percent of the premature deaths in the United States are caused by obesity, inactivity, and smoking, all of which ought to be preventable. Two-thirds of the country is overweight and a third is obese. Over the decades I have operated on a lot of patients with lung cancer, and every one of them was a smoker. So a natural starting point is to help people stop smoking and help them lose weight.

It might seem obvious but given the shocking statistics it clearly is not. It is a wonder why society as a whole has not managed to face up to this reality and change behavior adopting a more healthy life style. Hats off to the Cleveland clinic for “walking the talk” as he put it and they:

“stopped hiring smokers”

They received a lot of criticism and no doubt some attempts to combat this with law suits but have stood their ground. I can’t tell you the number of times I have entered a clinical facility through a back entrance past a line of employees, often still in surgical scrubs, smoking. It looks bad and as recently as yesterday I watched with disgust in what I see as concomitant behavior as one smoker tossed the still smoldering remainder butt onto the ground and walked off back into the facility – littering to boot.

But why is it that we still have according to paper prepared by Olivia Thornton, a high school graduate investigating the “Genetics vs. Social and Environmental causes of Obesity” do we still have over 30% of adults in the US obese and a tripling of of number of children who are obese since 1980. The problem is getting worse not better

according to the Center for Disease control (CDC,) 16%, over nine million people aged 6-11 are overweight

And it would be easy for other countries to sit back smugly and remain unconcerned but as the chart below shows this problem is worldwide and all the statistics suggest getting worse:

We are bombarded with adverts and marketing messaging to buy fast food and the circumstance and behavior reminds me of the sale and marketing of cigarettes and tobacco years ago. At that time people knew no better – turns out the tobacco companies did and even used the data to help create a more addictive product by adding and concentrating nicotine in their product. Years later the truth emerged and their complicit behavior was exposed and they have had their hands slapped.

We know that fast food is bad for us and parents around the world try hard ot encourage healthy eating. But I bet that many parents experiences are similar to my own that a home cooked ham burger just “doesn’t taste as good as a #insert favorite fast food brand hamburger here#”.

Here’s my jaundiced view of the problem and the fast food industry. They load everything up with sugar, its added to everything and they do this because sugar is addictive. If they add enough sugar they create an addict relationship with their consumers who find anything without the added sugar bland and unappealing.

Time will tell but it is hard to imagine why the addition of sugar is necessary and I have a hard time explaining the preference of my own family for fast food over better, more healthy and nutritious home cooked equivalents.

What do you think. Is it just my family that prefer fast food or do you have the same problems. Is it a conspiracy of the food industry or is the food industry just better at preparing tasty food. Let me know what you think.

Useful Advice for Weight Loss Without Breaking the Bank

Posted in Healthcare Information, Nutrition, Preventative Healthcare by drnic on January 26, 2009

Over 50% of weight loss success is done by individual work and not based on some expensive program or system. Personal experience can attest and saving your money for other purposes seems wise

The February issue of Consumer Reports reveals the secrets of successful dieters who lost weight without the aid of a diet program, medical treatment, books, or pills.

The pages are stocked full of sound advice and a simple 6 basic strategies:

  1. Watch portions. Carefully controlling portion size at each meal correlated strongly with a lower BMI. Successful losers were especially likely (62%) to report doing this behavior at least five days a week. So did 57% of the always thin, but only 42% of failed dieters.
  2. Limit fat. Fifty-three percent of successful losers and 47% of the always thin restricted fat to less than one-third of daily calorie intake five days a week or more, compared with just 35 % of failed dieters.
  3. Eat fruits and vegetables. Forty-nine percent of successful losers and the always thin said they ate five or more servings a day at least five days a week, while 38% of failed dieters did so.
  4. Choose whole grains over refined. People with lower BMIs consistently opted for whole-wheat breads, cereals, and other grains over refined (white) grains.
  5. Eat at home. As the numbers of days per week respondents ate restaurant or take-out meals increased, so did their weight.
  6. Exercise, exercise, exercise. Regular vigorous exercise — the type that increases breathing and heart rate for 30 minutes or longer — was strongly linked to a lower BMI.

Along with tips for healthful meals on a budget – this is a great report and resource.

More details from the Consumer Health Reports Diet and Nutrition Pages:

Six secrets of the slim
Realistic expectations
What you can do
Healthy and cheap
Stay-thin strategies
Downturn diet