Coaching and Leadership Training Can Help Med Students Avoid Burnout

Coaching and Leadership Training Can Help Med Students Avoid Burnout
Jack Penner
JP Mikhaie
Margaret Cary

By MARGARET CARY, JACK PENNER, and JP MIKHAIE

Burnout is one of the biggest problems physicians face today. We believe that addressing it early — in medical school — through coaching gives physicians the tools they need to maintain balance and meaning in their personal and professional lives.

We say that after reading comments from participants in our coaching program, “A Whole New Doctor,” developed at Georgetown University School of Medicine. This program, born almost by chance, provides executive coaching and leadership training to medical students, who are exactly the right audience for it.

Medical students tend to begin their education as optimistic 20-somethings, eager to learn and eager to see patients. After spending one or two years on the academic study of medicine, they move to the wards where they observe the hidden curriculum — a set of norms, values, and behaviors conveyed in implicit and explicit ways in the clinical learning environment.

In the hospital, convenience and expediency, deference to specialists, and factual knowledge tend to replace the holistic and patient-centered care that is lauded during the preclinical years. This new culture nudges some students to the brink of burnout and depression. Some consider suicide.

Jacob and Catherine (not their real names to avoid adding more pain to those who lost them) were colleagues of one of us (M.C.) in medical school. Each committed suicide as they moved from medical school to residency. Their deaths were never discussed by the faculty or the classmates they left behind.

As an antidote to these pernicious influences and secrecy, coaching helps foster students’ ability to “take the best and leave the rest” — to model behaviors that fit with their ideals and eschew those that don’t. The coaching relationship, an integral component of “A Whole New Doctor,” emphasizes the soft skills involved in medicine — empathy, effective communication, time management, and a positive outlook. In the same way clinicians learn the language of medicine and extend their knowledge base, they must also reflect, remain conscious, and work on these soft skills. Coaching can lead to increased self-awareness and self-control.

Our coaching program began when two of us (M.C. and J.P.) met and bonded over a shared love for essay writing. At the time, one of us (M.C.) was and still is a faculty member at the Georgetown University School of Medicine. The other (J.P.) was a second-year medical student.

The program works like this:

“A Whole New Doctor” is promoted to students in all four years. Those who are interested complete a six-question online application. Fellows (students who have completed the program) read the applications and invite students to join a weekend workshop. After the workshop, fellows interview the students who want a coach to set their expectations about coaching and to share their experiences with it. Students who want coaches then sign up and choose one from our Coach Bio Book, which is sent out to participants following the weekend workshop.

We structured “A Whole New Doctor” as a volunteer program because we have seen traditional professional development programs that require participation fail. In such programs, faculty members teach students with a homogeneous syllabus for all, despite each student having differing perspectives and experiences. We flip the learning environment, letting students guide themselves on how they will learn and grow, using their coaches as architects to help them build their futures.

The coaches, all professionally trained, are volunteers; none are formally associated with Georgetown University School of Medicine. (Even with the most trusted attending physicians, the power dynamics in medical education make it hard for students to open up.) The coaches create a nonjudgmental and emotionally safe atmosphere. The student participants express comfort knowing they can be vulnerable without worrying about their professional superior’s judgment.

Our first workshop in October 2016 had 13 participants. Since then, all 25 spots have been filled, with 100 percent participation in coaching in the last workshop.

In the first two years of the program, we’ve learned a lot. Here are some of the key takeaways:

Eliminate the hierarchy. Workshops and coaching sessions are title-free zones. Anyone who uses Dr., Ms., Mrs., Mr., or the like must pony up a $5 donation to the Hoya Clinic, a student-run clinic for the homeless. Titles reinforce the hierarchy and power dynamics in medicine.

Make participation voluntary. Students from all four years of the medical school are invited to join the weekend workshops but aren’t required to attend. We consistently hear about the value of getting students from different years together, of being transparent with and learning from each other.

Use adult learning techniques. Adults need to know why they should learn something other than “it will be on the test.” Medical students tend to be eager to learn what’s needed to become better physicians. They are also more responsive to internal motivators than external motivators.

Have students choose their coach. Giving students control over selecting their coach increases their investment in the coach-client relationship.

Recruit student champions. Fellows of the program understand the rigor of medical school and the experience of having a coach. These students serve as a bridge between their medical student colleagues and the coaches. In this position, the fellows work on their own kindness and listening skills, as well as learning by doing: delivering constructive criticism, working in teams, and delegating — all the skills (and more) that they might have learned about in theory in a required professionalism class.

Have fun. Making the program fun for students adds to their enthusiasm for staying the course in becoming physicians. It lets them explore and grow in a safe environment, and enjoy themselves in a communal setting, knowing they are working to improve the care they give their future patients.

We created “A Whole New Doctor” based on the hypothesis that coaching medical students would make a difference by helping them learn resilience, team leadership, and emotional durability. By connecting students with coaches who ask powerful questions, we aim to create a space for students to reflect on the tensions that naturally arise in medical education.

Our anecdotal evidence, based on interviews during and after the program, tells us we’re succeeding. Here are a few comments from the program’s fellows:

“AWND has taught me that first learning to navigate and connect with my own self is a necessary prerequisite for the connections I hope to build with my future patients.”

“Because of my coach, I feel more rooted to myself, patients and the practice of medicine and I will be a better physician because of it.”

“Coaching has helped me grow up and has led to my exploration of underlying motivations, the consequences of actions, and how to grapple with changing responsibility.”

You can see more of the feedback here.

Our approach isn’t the only one out there. The American Medical Association’s Coaching in Medical Education handbook for faculty members lists the handful of medical student coaching programs, each of which has been through curriculum committees, is run by faculty, and is mandatory.

“A Whole New Doctor” works like a startup within the medical school’s regulations. It uses business techniques like agility, continuous quality improvement, and customer feedback. It is run by volunteers for volunteers, because imposing coaching on anyone is ineffective and will leave both coaches and students feeling frustrated.

We’re now working on ways to bring the program to a larger audience, expanding to other medical schools by sharing the model or by working with faculty and medical students at their schools, handing over management within one to two years. It’s possible we will come up with a different model. If we can prevent one student/resident/physician suicide, we’ll have made a difference.

We believe that “A Whole New Doctor” provides medical students with the support and tools they need to become resilient, balanced, and fulfilled physicians. By fostering relationships between students and coaches, we are changing the conversation so students feel uplifted and empowered rather than emotionally exhausted and detached. And by changing the conversation we hope to change the culture of medicine.

Margaret Cary, M.D., is co-founder of “A Whole New Doctor,” clinical associate professor at Georgetown University School of Medicine, where she teaches the “Hacking Happiness” course, and CEO of The Cary Group Global.

Jack Penner, M.D., is co-founder of “A Whole New Doctor” and a first-year resident physician in internal medicine at the University of California, San Francisco.

JP Mikhaiel is vice president of publications for “A Whole New Doctor” and a third-year medical student at Georgetown University School of Medicine.

This post originally appeared on STAT News here.

The Folly of Self Referral

The Folly of Self Referral

By HANS DUVEFELT, MD

A lot of Americans think they should be able to make an appointment with a specialist on their own, and view the referral from a primary care provider as an unnecessary roadblock.

This “system” often doesn’t work, because of the way medical specialties are divided up.

If belly pain is due to gallbladder problems you need a general surgeon. If it’s due to pancreas cancer, you need an oncologic surgeon. If the cause is Crohn’s disease, any gastroenterologist will do, but with Sphincter of Oddi problems, you’ll need a gastroenterologist who does ERCPs, and not all of them do. Now, of course, if you’re a woman, that abdominal pain may actually be referred pain from an ovarian cancer, best treated by a GYN-oncology surgeon, which anywhere in Maine means a drive down to Portland.

The other day I saw an older man for a second opinion. He had been through one hand surgery for a small tumor many years ago in Boston, and another unrelated operation for a fracture in Bangor a few years ago. Then, after a non surgical injury, he developed stabbing pains in the same hand. Someone referred him to a neurologist for EMG testing, which was normal, and the man told me that was all the neurologist did, not a full consultation.

The man, who has traditional Medicare and thus the right to see any specialist who accepts Medicare, wanted me to get him in touch with the brilliant Boston hand surgeon. The man told me he wanted a diagnosis and a cure, and not just a bunch of pills, which is what his family doctor had offered him.

“I won’t take gabapentin, I mean, with all those side effects”, the man said emphatically.

“Did anybody suggest the diagnosis of Reflex Sympathetic Dystrophy or Regional Complex Pain Syndrome?” I asked.

“No, is that the name for what I’ve got?”

“I think so”, I told him. “And I don’t think even the most brilliant hand surgeon can help you. Around here, this is a problem that physiatrists, rehabilitation specialists, handle. I think you should see Dr. Paul DeBeck.”

“What would he do?”

“Confirm the diagnosis and probably offer you medication to start.”

The man frowned.

“The list of side effects is only a list of possibilities. It’s published for legal purposes, so you can’t sue the drug company for not warning you”, I explained. “I mean, would you drive a Jeep, or any car, on a public road if you read a document that said your gas tank could explode if you got rear ended, you could hit a moose, you could roll over if you went through a curve too fast, you could slide into a ditch on an icy road or you could get impaled if you drive too close behind a logging truck…”

“Anyway”, I continued, “I think your problem is not surgical, so going all the way to Boston would probably be a big waste of your time. I suggest you ask your doctor for a referral to Dr. DeBeck, right in Bangor. Then he could guide you from there, even if he doesn’t think it is what I think you have. He sees a lot of that type of problem, so he’ll know.”

The same day, I saw a woman with “hip pain”, which turned out to be on the lateral, outer side, of her hip and a little toward the back side. That spelled sciatica from lumbar disc disease. She had wanted an orthopedic referral. But in the northern half of Maine, almost none of the orthopedic surgeons deal with back problems, so an orthopedic referral would have been a terrible waste of time for her.

I sometimes wonder why it is that medical specialties are divided up the way they are; you need to know the diagnosis before knowing what specialist to see. I mean, why isn’t there a belly pain speciality? But, that is why it makes sense to see a generalist first. Plus, we are qualified to treat most cases of the majority of diseases people run into.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

Health in 2 Point 00, Episode 80 | Takeover Edition!

Health in 2 Point 00, Episode 80 | Takeover Edition!

Today on Health in 2 Point 00, where am I?! In Episode 80, Bayer’s Eugene Borukhovich is here to answer Jess’s questions—but don’t worry, he’s channeling his inner “Matthew”. Get Eugene’s take on Jawbone’s $65 million raise after its relaunch and find out if he disagrees with me about Noom’s recent $60 million raise. Jess also picks Eugene’s brain about what G4A is looking for in their challenge applications, so don’t miss out — Matthew Holt

Healthcare is Coming Home

Healthcare is Coming Home

SPONSORED POST

By DIANA CHEN

In an AARP survey of 2000 adults, 6 out of 10 respondents indicated they prefer to stay in their home and community for as long as possible. This desire increases with age; more than 75% of adults over 50 would rather remain in a familiar environment where they have strong connections to friends, neighbors, and businesses. However, for the elderly and people with chronic illness or disabilities, remaining at home can be difficult. These populations require services that are often provided at long term care facilities (e.g. nursing homes) and/or formal medical settings– which can be costly, inconvenient, and inefficient. 

Individuals of all ages across the health spectrum have also expressed interest in receiving health services in the home or community as a means to access higher quality and convenient care. With consumer demand for patient-centered care, the U.S. healthcare system has steadily steered away from institutional services in favor of home and community-based services (HCBS). Since 2013, Medicaid expenditures for HCBS has continued to exceed spending for institutional services. HCBS now accounts for 55% of Medicaid Long Term Care spending.

As the largest payor for healthcare in the United States, the Center for Medicare and Medicaid Services (CMS), is often the first to experiment and adopt new care delivery models. With Medicaid’s perceived benefits with HCBS, the CMS has also changed what is covered under Medicare Advantage (MA) to accommodate for the transition towards home and community based care. In 2018, CMS added “non-medical in-home care” as a supplemental benefit for 2019 MA plans. This year, CMS continued to broaden the range of supplemental benefits for MA 2020 to cover any benefits “that have a reasonable expectation of improving or maintaining the health or overall function” of beneficiaries with chronic conditions or illnesses.

In one short, powerful clause, CMS opens the
gateway to address previously neglected factors such as the home, social
environment, transportation, and more. of chronically ill patients. As listed
in the announcement, items and services that are covered may include but are
not limited to:

  • Meals furnished to the enrollee
    beyond a limited basis
  • Transportation for non-medical
    needs
  • Pest control
  • Indoor air quality equipment and
    services
  • Other benefits to address social
    needs

Health insurers and providers, especially home and community based care providers, are eager to take advantage of this addition. However, they need new ways to include such services in their care delivery. Unconventional care models, as well as novel technologies to support care delivery outside of medical institutions are essential. Therefore, the Robert Wood Johnson Foundation (RWJF), in partnership with Catalyst @ Health 2.0, has launched the “Home & Community-Based Care Challenge,” to encourage developers to create solutions that support the advancement of at-home or community based health care. Examples include but are not limited to:

  • coaching app to engage consumers with their
    healthcare
  • non-intrusive sensors for at home monitory of
    acute disease patients
  • apps to support caretakers with burnout

In this multi-phase challenge, innovators are
asked to submit tech-enabled solutions addressing home and community based
care. Subject matter experts will evaluate the entries and select the top five
teams who will move onto Phase II. The five semi-finalists will be awarded
$5,000 each to further develop their application or tool. Then, three finalists
will be chosen at the end of Phase II to compete at a live pitch event! They
will demo their technology in front of a captivated audience of investors,
provider organizations, and members of the media at a prominent health
conference. Judges will select the first, second, and third place winners live.
Winners will be awarded $40,000 for first place, $25,000 for second place, and
$10,000 for third place.

The challenge is open to innovators and companies at any stage of development. If you are interested in applying, the competition is now accepting Phase I applications and the deadline to submit is June 7th, 2019 11:59 PM EDT.

To learn more about the challenge, please visit the website. To sign up for updates on the challenge, please click here.

Diana Chen is a Program Associate at
Catalyst @ Health 2.0.

NEW: HardCore Health Podcast, Episode 1

NEW: HardCore Health Podcast, Episode 1

By MATTHEW HOLT

Apparently, podcasts are new, all the rage and minting billionaires every day!  So, of course, THCB had to have its own podcast, and here it is: HardCore Health

Now I’ve been doing “podcasts” (otherwise known as audio or video interviews) on THCB since before people actually had iPods (remember those, kids?). But apparently these days any punter can do an interview, call it a podcast and shove it up on Spotify. Hardcore Health is going to be a little bit different…

Hardcore Health will feature multiple guests, topics, and interludes brought to you by many co-hosts starting off with Jessica DaMassa and me. We’ll embed some (familiar) tidbits into the show including: Health in 2 Point 00, THCB Spotlights, and the WTF Health Show as well as some newer segments, including banter sessions between guests & rant sessions from health care experts. This first episode features Brian Kalis, Accenture’s “post” Digital Health expert & Niko Skievaski from Redox, and a little more.

I hope you enjoy our first episode below!

Matthew Holt is the founder and publisher of The Health Care Blog and still writes regularly for the site.

Reducing Churn to Increase Value in Health Care: Solutions for Payers, Providers, and Policymakers

Reducing Churn to Increase Value in Health Care: Solutions for Payers, Providers, and Policymakers
Saeed Aminzadeh
Niko Lehman-White

By NIKO LEHMAN-WHITE and SAEED AMINZADEH

Introduction
Every day and in every corner of the country, innovative health care leaders are conceiving of strategies and programs to manage their patients’ health, as an alternative to treating their sickness (see Figure 1).

The value-based contracts that have proliferated in this
country over the past decade and which now account for about half of the money
spent on healthcare allow these wellness investments to make good financial
sense in addition to benefiting patient health.

However, a phenomenon in health coverage in the US is
increasing costs, destabilizing care continuity and holding back the potential
of value-based care. It prevents us from making the long-term investments we
desperately need.

Understanding Churn

Churn refers to gaining, losing, or moving between sources of coverage. Every year, approximately a quarter of the US population switches out of their health plan. Reasons can be voluntary or involuntary from the perspective of the beneficiary (see Table 1) and vary from changes in job status, eligibility, insurance offerings, and preference, to non-payment of premiums, to unawareness of pending coverage termination.

Table 1. Examples of
reasons for voluntary and involuntary disenrollment from a health plan

Voluntary Disenrollment Involuntary Disenrollment
Decided too expensive Forgot to sign up
Decided to forego coverage Lost eligibility
Newly eligible for public insurance Couldn’t afford premiums
Moved Passed away
Want a different network Confused by application process
Unhappy with insurer  

 A study by the Center for Healthcare Research and Transformation asked Michigan policyholders whether they continued with the same plan they held the previous year. 72% of those surveyed with employer-sponsored insurance (ESI) stayed on plan. 62% of Medicaid beneficiaries did. Only 47% of those who purchased coverage on the individual marketplace kept their plan the following year.

Implications for care
and cost

Churn’s impact on medical care and quality is far greater than most realize. It impacts medication use (over 33% of individuals experiencing churn skip doses or stop taking a medication altogether) and often forces consumers to change doctors (primary care provider, specialist, or both). Patients with coverage interruptions have higher Emergency Department use, more hospitalizations, more serious mental health problems that lead to hospitalizations, and delays in the screening, detection and treatment of cancer. Churn also contributes to higher administrative costs.

It also disincentivizes long-term investment. Food-as-medicine
programs like Geisinger’s Farmacy, housing investments, and asthma programs make
less financial sense when a patient’s policy has a looming expiration date.

This issue is far less problematic in nations where
universal health insurance programs are offered. Since these programs will
likely cover a person for their entire life, they know that an investment in
wellness made at age 20 will still pay dividends when they’re 80 (an age which
they are more likely to reach because of those investments), which is one
reason why we see higher levels of funding for social programs in these
countries.

That situation differs drastically from the US, where
insurers know that most policies will be held for only a year or two and before
any investment has a chance to be returned, its target population will have
churned into another plan and their expensive investment ends up helping their
competitor. Thus, churn damages the financial return for the exact long-term
investments we need to make to improve health and decrease healthcare costs.

What follows are recommendations for changes that providers,
payers, and policymakers can make to minimize the impact that churn has on
their constituents and financial health.

Payers

One strategy that payers can use to combat churn is to focus
on engagement. Losing enrollees is expensive, and less engaged enrollees are
more likely to disenroll from their health plan. To truly move the needle in
today’s market, payers must be proactive and utilize sophisticated targeting
methods. A targeted retention program can be effective in minimizing this loss
if several guiding principles are followed.

  1. Pick the right members. Some members are simply higher risk to voluntarily disenroll than others.  A “one size fits all” marketing campaign targeted to every member with the same message will not provide the best results. The cost of this type of campaign will likely not be sustainable for the results it achieves.  For an effective, efficient campaign, leveraging insights from a high-performing predictive model which predicts the likelihood of voluntary disenrollment is essential.
  2. Try to understand why members might disenroll. Targeting the right members based on their likelihood to leave the plan is a great way to zero-in on the highest risk members. However, it’s knowing why these members will leave the plan that can help your organization to personalize the communication to these members. Otherwise, the organization risks missing the true barrier that the member is facing in terms of staying on plan. Keep in mind that members don’t necessarily leave because they’re unhappy with the plan: they might leave because they don’t understand or see the value in their current plan. In short, try to identify and resolve or address issues for members that are dissatisfied, and try to get the unengaged member to better engage with the health system.
  3. Stay ahead of network changes. If a member is high risk to leave the plan and you already know that you’re going to make changes to the network in this patient’s service area, try to stay ahead of this issue and address these issues upfront.  Consider ways to explain in plain English the reason for the change, your commitment to their service area, and the various options available to the member.  Any other type of communication to these members will result in making their flight risk higher, not lower.
  4. Try to coordinate member outreach with other plan initiatives. The end of the calendar year also signals a push for other important plan initiatives. Coordinating across teams in the organization is critical for reducing the number of outreaches any one member receives. If a member is in need of outreach for multiple initiatives (for example, staying on plan and undergoing a regular cancer screening), then either prioritize one of the communications or modify the communication outreach to avoid overwhelming the member.
  5. Know that this is a journey. Reducing voluntary disenrollment is satisfying from both a return on investment perspective and from a quality perspective.  However, it’s important to know that this is only a first step.  Now you can continually engage the member who was at high risk of leaving the plan to create longer term loyalty with the plan. Year-round “touches” and check-ins with members signals an understanding of the members’ challenges and begins to transform the plan from a “claims payer” to a “trusted source of information” in the eyes of the member.

Providers

A strategy that providers can deploy to defend against churn is to treat a patient’s eligibility date as a vital sign and proactively address an upcoming potential lapse in coverage, just like they proactively address an anticipated heart attack. Some innovative providers now consider health insurance status as a social determinant of health given the resulting likely disruption to continuity of care and downstream impact of that disruption to patient outcomes. By integrating a patient’s eligibility date with traditional data in, for example, an electronic health record (EHR), providers can trigger a low intensity intervention to keep the patient enrolled on plan and his or her care undisrupted (see Figure 2).

Some of the strongest support cases for this work has been completed by a group at Oregon Health & Science University (OHSU) whose body of published literature reads like a summary of our recommendation to providers (e.g., “Improve Synergy Between Health Information Exchange and Electronic Health Records to Increase Rates of Continuously Insured Patients”, “Health information technology: an untapped resource to help keep patients insured”).

Expanding inclusion of social determinants of health in the
EHR could be accomplished by developing new workflows to gather data, building
new data fields into the EHR, and creating linkages to other existing data sources.
Although the work at OHSU targeted state Medicaid-enrolled patients, patients
enrolled in individual marketplace plans, in Medicaid and Medicare Advantage
plans, and in ACOs could all benefit from clinic-based efforts to maintain
insurance coverage.

State and Federal Lawmakers
and Policymakers

Policymakers also have levers at their disposal to reduce
churn. This can be done in public insurance programs like Medicaid and CHIP,
and through individual market regulation.

Half of the US Medicaid population will lose their coverage within 12 months of signing up. This churn can have a particularly adverse effect on children, who are enrolled in Medicaid and CHIP in high numbers, frequently interact with the health care system, and take time to build trusting relationships with their caretakers.

Churn is especially prevalent in Medicaid because its eligibility is determined by month-to-month income, which tends to vary significantly in the low-income population covered by the program who frequently transition in and out of jobs. Eligibility determinations add another layer of complexity. Work requirements as a condition of Medicaid eligibility, which some states have proposed or implemented as a way to increase civic participation and reduce Medicaid enrollment, will further contribute to churn not only because of noncompliance with the requirement, but also because of confusion and technical difficulty with submitting proof of civic engagement. Only 1,525 of the 69,041 beneficiaries subject to Arkansas’ new work requirement program (imposed in May 2018) both complied with and accurately reported data for their 80-hour-per-month mandate.

Several contributors to public payer churn have nonpartisan
solutions. Many enrollees stumble during the renewal process, so Medicaid
programs would do well to automate the process or simplify renewal forms and
translate them into appropriate languages. Some suggestions to have included:

  • Express lane eligibility: Use data from other benefit systems such as SNAP or TANF to determine Medicaid eligibility.
  • Continuous eligibility: When someone enrolls, keep them on the program for a minimum amount of time (usually 12 months).
  • Administrative verification of income: Make the government verify income eligibility, rather than requiring beneficiaries to submit proof.
  • Consumer assistance programs: Develop programs that assist people with eligibility and enrollment questions.
  • Increase government incentives to practice in underserved areas and accept publicly funded insurance: Limited geographic access and long wait times decrease the value of health coverage. Increasing access for the underserved will make Medicaid coverage more worthwhile to consumers.
  • Annualized income determination: Assess income on a yearly basis rather than monthly, to reduce the impact of income fluctuations.

Federal policymakers can address churn in individual and
SHOP markets by allowing carriers to decrease their premiums or cost-sharing for
consumers who renew an individual or small-group plan they held the previous
year. This is already common practice in auto and home insurance policies. Allowing
state insurance commissioners offices to bestow this “incumbent price
advantage” in health insurance would require a change to the Affordable Care
Act, which only allows plan prices to vary individually based on age, smoking
status, and location. This proposal would pose a barrier to entry for new carriers,
so the competitive ramifications of any “price break” policy should be fully
evaluated by a state before being allowed.

Conclusion

Churn has vexed insurance executives for decades and is considered by many at this point an inevitable challenge. But now that the value-based movement has led to a refocusing on social determinants of health, incentives are aligned to address this issue. This solution may be a key step towards a healthcare system focused on investing in health rather than in treating illness.

Niko has a background in research and consulting and enjoys writing about and solving problems facing the US health care industry.

Saeed has more than 25 years of health information technology experience, with a track record of building high-performing organizations designed to solve complex business problems.

Calling All Tech Companies & Early Stage Innovators Health 2.0 Annual Conference Applications Are Open!

Calling All Tech Companies & Early Stage Innovators Health 2.0 Annual Conference Applications Are Open!

SPONSORED POST

By IRENA LUO

Considered a major hallmark of the Health 2.0 Annual Conference, these two opportunities for tech presentations are a chance for entrepreneurs and startups to gain visibility for their products with potential investors, partners and peers. The conference—scheduled from September 16–18 in Santa Clara, California—is now accepting applications from companies who want to demo their health tech innovations or pitch for a chance to be named Startup Champion at the HIMSS event.

Health
2.0 Live Tech Demos

Applications
close June 7, 2019

Last
year at the 2018 Health 2.0 Annual Conference, more than 100 innovative
companies, including Aaptiv, Healthify, and Heart Flow, showcased products
designed to help transform healthcare. In 2019, the Health 2.0 team is changing
things up and reworking their breakout session schedule to allow more focus
around the main stage programming. What does this mean for our demos? With more
streamlined programming, we’re upping the ante for our tech demo applicants and
selecting the most intriguing, adaptable, applicable products to be featured at
the 13th year of the conference. Chosen companies will either demo
their tech in standalone presentations or as part of larger panel sessions.

How to apply:

  1. Go to the application page
  2. Create a login
  3. Click “Health 2.0 Live Demos 2019”

Health
2.0 VentureConnect Pitch Competition

Applications
close July 8, 2019

For
startups and entrepreneurs, the rapid-fire pitch competition is an opportunity to get valuable
exposure for their products, make connections with some of health tech’s
biggest and most active investors, and ultimately win the title of Most
Fundable Startup. Last year, 60 companies competed in the competition. Mira
and Avhana Health won in the contest’s consumer and provider tracks, respectively.

The
Health 2.0 VentureConnect Pitch competition brings together vetted seed
companies through raising Series A companies to pitch their innovative product
live on stage during rapid-fire presentations. The prize? Being named the most
promising startup by the venture capitalists and corporate investors judging
the competition. Six competition finalists—three consumer-facing startups and
three provider-facing ones—will compete to win in their category.

How to apply:

  1. Go to the application page
  2. Create a login
  3. Click “Health 2.0 Pitch Competition 2019”

Irena Luo is a Producer at the Health 2.0 Annual Conference, A HIMSS Event

We Are Not A Dashboard: Contesting The Tyranny Of Metrics, Measurement, And Managerialism

We Are Not A Dashboard: Contesting The Tyranny Of Metrics, Measurement, And Managerialism

By DAVID SHAYWITZ

The dashboard is the potent symbol of our age. It offers the elegant visualization of data, and is intended to capture and represent the performance of a system, revealing at a glance current status, and pointing out potential emerging concerns. Dashboards are a prominent feature of most every “big data” project I can think of, offered by every vendor, and constructed to provide a powerful sense of control to the viewer. It seemed fitting that Novartis CEO Dr. Vas Narasimhan, a former McKinsey consultant, would build (then tweet enthusiastically about) “our new ‘control tower’” – essentially a multi-screen super dashboard – “to track, analyse and predict the status of all our clinical studies. 500+ active trials, 70+ countries, 80 000+ patients – transformative for how we develop medicines.” Dashboards are the physical manifestation of the ideology of big data, the idea that if you can measure it you can manage it.

I am increasingly concerned, however, that the ideology of big data has taken on a life of it’s own, assuming a sense of both inevitability and self-justification. From measurement in service of people, we increasingly seem to be measuring in service of data, setting up systems and organizations where constant measurement often appears to be an end in itself.

My worries, it turns out, are hardly original. I’ve been delighted to discover over the past year what feels like an underground movement of dissidents who question the direction we seem to be heading, and who’ve thoughtfully discussed many of the issues that I stumbled upon. (Special hat-tip to “The Accad & Koka Report” podcast, an independent and original voice in the healthcare podcast universe, for introducing me to several of these thinkers, including Jerry Muller and Gary Klein.)

A good place to start may be a 2013 essay by Kenneth Cukier and Viktor Mayer-Schönberger in Technology Review, warning,

“We are more susceptible than we may think to the ‘dictatorship of data’—that is, to letting the data govern us in ways that may do as much harm as good. The threat is that we will let ourselves be mindlessly bound by the output of our analyses even when we have reasonable grounds for suspecting that something is amiss.”

Citing the example of metrics-obsessed Vietnam-era Secretary of Defense Robert McNamara, Kukier and Mayer-Schönberger conclude,

“Big data will be a foundation for improving the drugs we take, the way we learn, and the actions of individuals. However, the risk is that its extraordinary powers may lure us to commit the sin of McNamara: to become so fixated on the data, and so obsessed with the power and promise it offers, that we fail to appreciate its inherent ability to mislead.”

Jerry Muller

Historian Jerry Muller, in his essential new book The Tyranny of Metrics, offers what might be the best summary of how McNamara-like thinking has pervaded our own; in the same way that Steven Levy, in 1984, wrote that the (recently introduced) spreadsheet “is a tool, but it is also a world view,” Muller offers a similar view of metrics, which he worries has evolved into a fixation.

“The most characteristic feature of metric fixation is the aspiration to replacement judgment based on experience with standardized measurement. For judgment is understood to be personal, subjective, and self-interested. Metrics, by contrast, are supposed to provide information that is hard and objective. The strategy is to improve institutional efficiency by offering rewards to those whose metrics are highest, or whose benchmarks or targets have been reached, and to penalize those who fall behind….

To be sure, there are many situations where decision-making based on standardized measurement is superior to judgment based upon personal experience and expertise…. [U]sed judiciously, then, the measurement of the previously unmeasured can provide real benefits….

If what is actually measured is a reasonable proxy for what is intended to be measured, and if it is combined with judgment then measurement can help practitioners to assess their own performance, both for individuals and for organizations. But problems arise when such measures become the criteria used to reward and punish – when metrics become the basis of pay-for-performance or ratings.”

He observes that “metrics fixation leads to a diversion of resources away from frontline producers toward managers, administrators, and those who gather and manipulate data.”

Muller’s key takeaway: “Not everything that is important is measurable, and much that is measurable is unimportant.”

Nassim Taleb

The Black Swan author Nassim Taleb has also worried about the way we think about data, writing in Antifragile (and excerpted here),

“In business and economic decision-making, data causes severe side effects —data is now plentiful thanks to connectivity; and the share of spuriousness in the data increases as one gets more immersed into it. A not well discussed property of data: it is toxic in large quantities —even in moderate quantities….

The more frequently you look at data, the more noise you are disproportionally likely to get (rather than the valuable part called the signal); hence the higher the noise to signal ratio.”

Indeed, in testimony to Congress following the financial crisis, Taleb said,

“Some may use the argument about predicting risks equal or better than nothing; using arguments like ‘we are aware of the limits.’ Risk measurement and prediction —any prediction — has side effects of increasing risk-taking, even by those who know that they are not reliable. We have ample evidence of so called ‘anchoring’ in the calibration of decisions. Information, even when it is known to be sterile, increases overconfidence.”

Frank Pasquale

A particularly cogent summary of our present state has been offered by law professor Frank Pasquale, whose 2017 essay on professional judgment, while a bit of tough sledding, is nevertheless a required read.

Pasquale zeros on the reductionist essence of many data-focused approaches,

“Robotics and AI, including even advanced machine-learning systems, comprehend professions as jobs, jobs as tasks, and tasks as observation, information processing, and actuation. Though such strategies to divide labor are sensible in many industrial contexts, they ignore the irreducibly holistic assessments that are hallmarks of good judgment.“

Yet, Pasquale writes,

“Instead of reductionism, an encompassing holism is a hallmark of professional practice—an ability to integrate facts and values, the demands of the particular case and prerogatives of society, and the delicate balance between mission and margin….

For over a decade, business books have exhorted managers to be ‘supercrunchers’— numbers-obsessed quantifiers, quick to make important decisions as ‘data driven’ as possible. There is an almost evangelical quality to this work, a passionate belief that older, intuition-driven decisions are a sinful relic of a fallen world….

The commensurating power of numbers, sweeping aside contestable narratives, promises a simple rank ordering of merit, whether in schools, hospitals, or beyond. Measurements are not simply imposed from the top down. They also colonize our own understandings of merit.”

Such managerial approaches, Pasquale recognizes, elevate “the ‘data-driven,’ while minimizing the all-too-human process of gathering, cleaning, and analyzing data.”

Pasquale also reiterates Muller’s point that metrics “often distort the social practice that they ostensibly measure,” citing Campbell’s Law: “The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.”   (This idea has also found expression in Goodhart’s Law, essentially, “When a measure becomes a target, it ceases to be a good measure.”)

Finally, while emphasizing that “all-pervasive quantification and metricization” is not “the ineluctable logic of economic progress,” Pasquale recognizes that, “For true believers in metrics and standardization, problems with existing metrics are simply a prompt to improve metrics.”

My Reflections

The authors cited above deserve careful read and thoughtful critique; I’ve quoted them to provide a sense that there’s an alternative world view to the one in which it feels so many of us live, whether working in a multinational corporation or a local non-profit hospital. It is a world dominated by a religious faith in managerialism, the idea that the right way to improve performance is to measure more, capture more data, and use these data to manage in an increasingly granular fashion, in a behaviorist style that can be traced back to Taylor but often feels more indebted to Pavlov.

To be clear, it’s not that the critics can’t appreciate the utility of data, of measurement, of metrics; they go out of the way to explain how each of these can be critically important – an invaluable tool. The issue seems to be that we’ve taken a tool, an approach, a mindset (to return to Levy’s phrase), and started to apply it almost indiscriminately, with a near-religious fervor. We do this because we can – there are always more data to capture, and there are very real examples where data provides essential insight that human intuition alone might have missed or already missed.

But the idea that data enables human biases to be replaced with pure objectivity is a fantastical illusion. Human judgment is biased, but the worship of data doesn’t magically transport us to The Realm Of Wholesome Objectivity. In the world of data, bias abounds, permeates all we do – including how we decide what data to collect (and decide what is “collectable”), how we decide how to measure, how we decide how to analyze, and what we decide to do with the results of these analysis.

The answer isn’t to reject all data, measurement, or metrics, but rather to ensure that these tools aren’t accorded undue respect, or given an unearned benefit of the doubt. We need to leverage data and metrics selectively and judiciously, just as we should recognize and leverage selectively the accumulated wisdom of reflective practitioners in a range of domains. We must also recognize the value of tacit knowledge and accumulated expertise in some areas, while at the same time thoughtfully challenging received wisdom and cherished assumptions.

As Klein and Kahneman observed in a captivating 2009 essay attempting to synthesize their contrasting views of expertise, physicians (and they believe, most professions) exhibit “fractionated expertise,” meaning that there are situations where expert wisdom deserves to be trusted, and situations where it shouldn’t be (the former captivate Klein, the later, Kahneman).

I suspect Klein and Kahneman are correct that “the fractionation of expertise is the rule, not an exception,” but I worry that we’ve lost our equilibrium, and have become so obsessed with the failure of expertise and intuition that we’ve neglected to leverage deep reservoirs of existing expertise, especially among experienced practitioners. Meanwhile, we seem to have developed an excessive faith in the ability of putatively objective data and detached analytics to deliver us.

If there’s one thing managerialism offers above all else it’s an implementable framework, an all-purpose way to approach most every organization, no matter how large, and every problem, no matter how difficult. It’s thrived in no small part because it clearly works in some well-defined situations, and while it may fail abysmally in others (pharma R&D comes to mind), there doesn’t seem to be an alternative worldview capable of replacing it, causing the cycle to persist, the behavior patterns to become ever more ingrained.

I recently asked Muller about this concern, via Twitter, wondering if there was another way to think about this. He replied, “Management based upon experience, expertise in the subject matter of the organization, and demonstrated talent within the organization; along with the judgment to use measurement and data selectively and efficiently.”

“I can’t see how competent experts could ignore metrics,” Muller continued. “The question is their ability to evaluate the significance of the metrics, and to recognize the role of the unmeasured.“

This captures, perfectly, where we need to be headed, especially as we contemplate how to meaningfully improve areas like drug development and healthcare delivery. Data sciences and technology could, and must, play a vital role. But they haven’t earned the right to be considered an end in themselves. They represent potentially valuable tools, ideally in the hands of experienced and inquisitive practitioners, who uniquely appreciate the subtleties of their domain – McClintock’s phrase “feeling for the organism” comes to mind; who have the humility to recognize the limits of knowledge; and who will actively seek to leverage the benefits potentially offered by data, analytics, and measurement, thoughtfully applied.

Addendum: Further Reading

In addition to the books and articles cited above, readers might also enjoy:

This Bill Gardner essay about checklist burden, and how well-intentioned but excessively narrow metric-based thinking can lead to unintended, suboptimal outcomes.

This Financial Times op-ed Nassim Taleb and I wrote in 2008 about the challenges of industrializing drug discovery.

This Atlantic essay I wrote about the impact of reductionism in business strategies around healthcare cost reduction.

This short Forbes piece I wrote about fetishization of metrics.

This engaging talk by OptumLabs CMO Darshak Sanghavi (discussed by on our recent TechTonics podcast with Sanghavi and co-host Lisa Suennen) highlighting (through analogies with reality TV!) the importance of measuring what matters – and understanding what matters.

This engaging talk by OptumLabs CMO Darshak Sanghavi (discussed by on our recent TechTonics podcast with Sanghavi and co-host Lisa Suennen) highlighting (through analogies with reality TV!) the importance of measuring what matters – and understanding what matters.

This piece originally appeared in Forbes here.

Health in 2 Point 00, Episode 79 | Noom, DispatchHealth and Kaiser Permanente

Health in 2 Point 00, Episode 79 | Noom, DispatchHealth and Kaiser Permanente

Today on Health in 2 Point 00, Jess is in Italy…and has me up far too early in the morning for this episode. On Episode 79, Jess asks me for an update on uBiome after their raid by the FBI. We also talk about nutrition startup Noom’s $58 million raise and clinician house-call platform DispatchHealth’s $33 million raise. In other news, Kaiser Permanente is launching a network to integrate the social determinants of health with their EHR. –Matthew Holt

Last Month in Oncology with Dr. Bishal Gyawali: April 2019

Last Month in Oncology with Dr. Bishal Gyawali: April 2019

By BISHAL GYAWALI, MD

Keynote speech on the JAVELIN not going far enough to improve survival

The treatment landscape for metastatic renal-cell carcinoma has changed dramatically with the introduction of immunotherapies. Unfortunately though, we are promoting combinations over single agents without having much idea of added benefit of each drug. This is an important issue because when we combine two drugs, the only thing we are certain of are the added toxicities. PD-1 inhibitor nivolumab had improved OS when given in second line, however nivolumab was tested in combination with ipilimumab (not as a nivolumab monotherapy) in the first line trial. Now, pembrolizumab and avelumab have followed suit, although their combination partner was axitinib – a VEGF inhibitor. The control arm was sunitinib for both of the trials of pembrolizumab plus axitinib (KEYNOTE 426) and avelumab plus axitinib (Javelin 101). This is a little surprising because we are testing A B versus C, where both A and B haven’t been approved for the given setting – axitinib was approved for RCC in second line. Both these combinations improved PFS versus sunitinib but only the pembrolizumab combination has shown improved OS. However, I have doubts about the contribution of axitinib to these results. What would the outcome be if pembrolizumab alone is followed by sunitinib in second line? It is important to note that only one third of patients who discontinued sunitinib received PD-1 inhibitor subsequently in the KEYNOTE 426 trial. The important question for patients and clinicians would be to consider a survival difference had most of these patients received a PD-1 inhibitor subsequently. As for avelumab, the JAVELIN trial hasn’t reached as far as pembrolizumab and nivolumab have reached: The OS benchmark – so let’s reserve this combination until we see that benefit.

Have we successfully landed on the COMET?

We should remember that this combo-mania with PD-1/PD-L1 inhibitors may also backfire. Previously, the RCTs of nivolumab and pembrolizumab combos were halted in multiple myeloma for higher deaths in the combo arms. Another RCT IMblaze 370 also reports that atezolizumab, alone or in combination with cobimetinib, failed to improve survival versus regorafenib in patients with metastatic colorectal cancer.  This time again A B failed versus C although C in itself is a drug with very marginal benefits in this setting. Also, I don’t understand testing A plus B combo when both A and B are unapproved for the disease.

SABR-COMET was an open label phase 2 RCT which tested if the use of stereotactic ablative radiation therapy (SABR) in the treatment of oligometastases (up to 5) improved survival. Among 99 patients randomised 2:1 to SABR plus standard care or standard care alone, the median OS was found to have improved dramatically by 13 months in the SABR group (41 v 28m, HR 0.57, p = 0.090). The authors conclude appropriately that “Phase 3 trials are needed to conclusively show an overall survival benefit.” I have no criticism against this study. However, I have criticism against some top experts claiming that this trial is already practice changing. No, this is a phase 2 trial whose objective was to determine if this intervention was worth testing in a phase 3.  The trial is positive, so the appropriate conclusion is “let’s test this in a phase 3 trial”, not “let’s change practice today”. It is also worth noting that the intervention had a 4.5 percent treatment-related mortality rate! We should never jump to conclusions, and kudos to the authors for concluding appropriately in the report of this public-funded RCT.

You may want to imagine how a similar RCT may have been published had it been an industry-sponsored drug trial. Well, you don’t need to imagine hard because we already have an example. In this partially industry-funded phase 2 RCT of regorafenib in 42 patients with relapsed metastatic osteosarcoma, the conclusion reads: “Regorafenib should be considered a treatment option for patients with relapsed metastatic osteosarcoma”. Guess what the results were to enable such a conclusion? The gain in PFS (primary endpoint) was less than 2 months. And the OS is in fact…wait for it…less in the regorafenib arm than the placebo arm by more than 2 months with a hazard ratio of 1.26 (95% CI, 0.51-3.13)! Can you now see how bias creeps in even in high-profile journals? SABR-COMET, a public-funded randomised phase 2 of 99 patients with both an OS endpoint and an OS difference of more than a year concludes (appropriately) that we should test the intervention in a phase 3 trial, while an industry-funded phase 2 RCT of a drug in only 42 patients with a PFS primary endpoint concludes that the drug should be considered a treatment option, despite the benefit in PFS being less than 2 months – but the detriment in OS (although not significant) being more than 2 months. I’m puzzled by the need to sugarcoat these results, especially on the background of olaratumab’s recent failure to improve OS in phase 3 despite showing improved OS in phase 2 in patients with soft tissue sarcoma. Speaking of conclusions based on phase 2 trials, a trial reports that “administration of nab-paclitaxel plus gemcitabine-cisplatin may prolong survival vs administration of gemcitabine-cisplatin alone for the treatment of advanced biliary cancers”. You, like me, may be wondering why test nab-paclitaxel instead of the much cheaper paclitaxel. Well, this trial was funded by Celgene. So it may not come as a surprise to you at all that this was a single arm trial and that “versus” in the previous statement was comparison to historical controls. Thankfully though, they are testing this in a phase 3 RCT.

The time to study metastatic cancer survivorship was yesterday

In one of the most poignant pieces on cancer survivorship written by two cancer survivors, we realise how the oncology community has forgotten the needs to address quality of life issues of metastatic cancer survivors in our enthusiastic quest of chasing marginal gains in oncology. The authors poignantly describe the various issues including hope, financial toxicity, psychosocial needs, caregiver issues etc. that trouble metastatic cancer survivors. Although we can be proud that we now have millions of cancer survivors living long term, we can’t continue to ignore their issues in research and clinical practice. The best time to study metastatic cancer survivorship was yesterday, the next best time is today.

Let me take a selfie

Is it ok to provide full approval to cancer drugs on the basis of non-inferiority trials especially if these drugs don’t offer any other benefits such as ease of administration, lower cost etc to justify the non-inferiority design? I discuss these issues on the background of recent approval of lenvatinib in hepatocellular cancer based on non-inferiority trial in a JAMA Oncology viewpointwritten with Dr. Aaron Kesselheim.

Dr. Gyawali is a research fellow at Program On Regulation, Therapeutics And Law (PORTAL) at Brigham and Women’s Hospital/Harvard Medical School. The opinions expressed herein are his own. This post originally appeared on ecancer here.