Healthcare is an enormous part of our economy and arguably the part of our lives that is the most fundamentally important to determining our quality of life and happiness. But there is so much that is inefficient and can be improved. I wanted to briefly describe a few of the major problems, trends, and opportunity areas that excite me about the field.Doctor payment models
Problem: Most doctors get paid on a fee for service model rather than an outcome model. This incentivizes more treatment and tests and does not punish readmissions/disease relapses. Measuring quality and outcomes in medicine is actually a very ill-defined and difficult challenge in and of itself. A medical problem could come from four areas (doctor's advice, patient genetics, patient choices, and external events), with the doctor only involved in one of them. Nonetheless, there must be something better we can do than the current state of affairs.
Somehow, it would be nice to align doctor incentives with patient health and allow more fluid access to care when people need it. Some of the current quality-tied compensation schemes are a step in that direction, but they are too narrowly defined and promote gaming the system. Projects like "medical homes
" as well as some HMOs are making good progress in this direction. It would be nice if primary care doctors earned more so we had more of them (we are in desperate shortage
now, which will only exacerbate with health care reform). They should also have more authority and pay when they keep their patients healthy as well as earn money for extra counseling around lifestyle issues (currently they don't earn for that).Insurance company incentives
Insurance companies should incentivize health, not just pay for cures. While it is difficult, prevention is preferable to treatment. Not just HMOs, but all insurance companies should be paying our gym memberships and giving us rewards for using them (check in at the gym), subsidizing our expensive Whole Foods organic food purchases and multivitamins, giving us money for not smoking or drinking, etc. I learned that the reason a lot of this doesn't happen is that people switch individual insurance carriers frequently, and the benefits of positive lifestyle choices are only reaped over the long-term (by which point the insurance company might have been changed out).
Insurance companies that see patient claims as "losses" as opposed to normal operating costs seem backwards. I want companies that will incentivize health and be customer-service organizations, chosen by people for their helpfulness rather than simply as a lesser among evils.Electronic medical records
There are many EMR systems out there already, and the government provides incentives to install them and "meaningfully use" them. However, from doctors I've spoken to, I've learned that most are still clunky and limited, aren't designed with the doctor and patient in mind (i.e., not human-centered), and most painfully of all, aren't interoperable. The vision of electronic records is that they would enable people to carry their data across providers and improve communication across organizations, but that hasn't yet been solved. Many people complain
of doctors who don't communicate effectively, and part of it is behavior change and training, but another part is the tools available.
I'm wondering whether countries that offer "universal healthcare" are different in regards to the problems mentioned above. I know they are much worse in terms of doctor waiting times (which are expected to increase substantially in the US after health care reform) and have worse access to the top-of-the-line medical tech. But are their doctors more collaborative? What other problems do they have?Real-time home monitoring technology
This is very closely related to what Paul Graham wrote about as "ongoing diagnosis
." We only seek care when we have symptoms, as opposed to knowing much earlier if something is sub-optimal in our body and correcting it then and there. This is very aggressive and difficult from the technology standpoint, but that's why it also makes it really exciting for me. I've always dreamed of a machine that can scan my body quickly at home and tell me if I have broken bones or infections. Taking this one step further, it would "push" this info to me whenever my body state changes adversely instead of me having to repeatedly poll for it. This seems really cool and also really hard.
I recently spent a week volunteering as a camp counselor. I've never done anything like that, and I was really nervous about the experience beforehand. This camp was for kids with chronic or severe illnesses. I had never really worked with kids outside of Reading to Kids
, and in particular I had never done a lot hands-on in the medical world.
I ended up learning a ton -- about medicine, kids, philosophy, and myself. It was a lot of fun, and I'm sad it went by so quickly. Below are my top 10 lessons learned from the experience.1. All kids share something unique and human in common.
I was initially afraid of the kids, worrying about what they'd be like and how I could possibly "lead" them. It turned out that all the kids were silly, playful, and interested in the same things: sports, art, creativity, imagination, cars, video games, and super heroes. We had a group of boys aged 7 to 11, and there was something core that they all shared as boys and connected through.
They bonded as boys and as friends, not as kids who were sick. They were happy, optimistic and interested in having fun. That was so awesome to see and facilitate.2. Treat people as people, not as illnesses or ideas.
The entire experience was about having fun at camp, doing everything you've wanted to do, and having all your medical/physical needs met behind the scenes. While the medical stuff could've been front and center, it rarely emerged or was discussed. Everyone was having too much fun.
I recently saw the movie The Intouchables
. Not only was this movie awesome because it was in French, but it was a deeply moving story (I'm not ashamed to admit that I cried at the end for a while and am still thinking about the movie). It was about an amazingly authentic and honest man who took care of a handicapped man and treated him like a person, not as a handicapped person.
It's so easy and natural for us to label and categorize and generalize. It's much harder but much more effective to deal with the facts of each person's situation and approach each individual as a human with desires and a separate experience, one that might be very similar to your own in many ways.3. Spending time among men doing manly things is great.
I got to spend a week bonding with guys and spending time as men together. it's not something I'm lucky enough to do on a regular basis, and it's something that I've learned is important in a man's development and growth. It was fun to beat our chests, play competitive games, and jointly write our cabin's "Man Laws" which we enforced with vigor and pride.
Because the camp was pretty much technology-free for a week, I learned that I can survive perfectly well on 30 minutes of email once per day. That was pretty liberating.4. Finding your inner kid isn't so hard; you just have to be open to it.
When the camp started, I realized how out of place and inside my head I felt. We were doing cheers and games, and I kept worrying about how silly I looked. I wondered how I could let myself be more free, how I could let myself yell and sing. I found that just by practicing some of the camp cheers and being around others who were already more "loose" and open, I could open up too. Doing art and sports helped as well.
I'm naturally so much in my head that I found I had trouble relaxing at times, and I kept thinking that my own personality wasn't as funny or silly as some of the other more funny counselors and guys in our group. It took practice and intention, but I found that I could accept myself and feel silly like a kid too if I let my guard and shell down for a bit. It was interesting going through the experience of being a kid while also being an adult.5. Counselors at camps can have a lot of fun, for the kids and for themselves.
We played awesome games, did improv activities, sang lots of funny cheers that I still repeat to myself at home for fun, and ate lots of s'mores. It was awesome. Even during training, with no kids around, we were doing cheers and games. I learned a big lesson about camp culture: everyone at camp is positive, happy, open, and (literally) cheerful all the time, and that's a cool way to be.
Maybe this "fun" wears off after a while, but I hope not. I know this "fun" can also get tiring for the staff and takes a lot of work, so I feel very appreciative of and impressed by all the staff who works at camps all summer. I can see the dedication and endurance that requires, and I applaud it. I was so impressed by how down to earth, respectful, energetic, positive, and smart all my fellow counselors were.6. Kids are great at taking care of themselves, and sickness can force them to grow up quickly.
I was really impressed how most of the kids knew about their conditions and knew how to deal with their own treatments very well (keeping the adult nurses on their toes). I can see how experiences cause them to think about "adult" topics like health and medications earlier than one would have to if one didn't have a condition, and I acknowledge what's in them that allows them to grow up quickly in this regard.7. in dealing with kids, tone of voice and parenting tricks help a ton.
In dealing with the campers in my room, I quickly learned that adult tone of voice and reason/rationality don't work that well. I needed to learn a special tone of voice, and I found myself emulating some of the more experienced counselors' words and tone, and that worked much better. It felt to me like the tone sounded more female, higher pitched, which makes me wonder how a modern "man"/father can raise kids without mimicking a mother. I realized that camp is a good place to learn parenting.8. Games and daily rituals help teach lessons.
There were lots of little games and rituals that occurred that gave kids a good structure for the day and also taught them valuable lessons. I thought it was cool how they were learning in such a casual way. For example, there was a song when a meal ended, and it meant everyone would dance and clean up their own dishes. There was a game to see who would get to wash their hands first (and a song for hand washing). There was a ritual of making a wish before a meal. There was a song for drinking water and hydrating. There was a Book of Firsts that announced the proud moments of "firsts" of the various campers' accomplishments for the day. There was also the concept of "warm fuzzies," which were written or oral acknowledgements of each other, good vibes people would send to each other with special hand gestures or little notes placed in individually-designed bags. That was such a cool ritual.
If people acknowledged each other in the real world and sent each other warm fuzzies like we did at camp, the world would be a better place.9. Daily quiet rest hour in the afternoon and cabin chat at the end of day were a great way to collect one's thoughts and lessons learned from the day.
A time to rest in the middle of the day and a time to process the day's highs and lows provided some great opportunities for reflection, introspection, bonding, and learning about each other and ourselves. This ritual has direct applications for business and adult relationships.10. Camp life -- 24/7/365.
The lessons and ideas from "camp" can be applied to real life, every day. Cheers can be great even (maybe especially) for adults to relax, cheer up, and drop our pretenses. Camp makes you ask yourself, "How can I practice giving love fully?" Camp is good practice for this, and so is real life. Can you keep an attitude of being in camp all the time in the real world, acknowledging others around you authentically and being positive? I think you can; it just takes some trying and being silly.
As part of a class I took on biotech, we were assigned to read Science Business
by Gary Pisano. I learned a lot from the class and this book, and it really answered a question I've had for a long time: Why does science/medicine move so much more slowly than technology in general?
I learned that the biotech industry as a whole has been barely profitable since its inception, and that there is a severe productivity crisis (productivity as defined by cost per successful drug has been dropping over time, which is very different from something like computer processors which have been dropping in price over time). There is a big "valley of death" between discovery of a compound or process and commercialization. It takes 10 years and $1 billion
to get a drug to market, and 1 in 5,000 drugs makes it. WHOA.
People are always optimistic about biotech revolutionizing health, and it hasn't lived up to this potential yet. The book explains many reasons for this and suggests some different approaches and solutions, none of which seems easy or straightforward.
My full notes are below. I'm curious to see how the industry evolves in the future, as many lives could be saved and improved if things change drastically.
I. Preface: The rise of a new industry and a big question
a. Big hopes but disappointing financial returns over time
b. Biotech firms not more productive in R&D than big pharma
c. Fundamental business problems created by science
d. Functional requirements of sector; performance comes from how well it’s managing these (poorly)
i. Risk management
e. Monetizing IP leads to bad info flow, fragmentation, proliferation of new firms
f. Biotech can’t just adopt same methods as high-tech
g. Can sci be a biz?
h. Some businesses doing basic sci; some universities treating sci like biz (selling IP, starting co’s)
i. 30 year history of biotech sector data analyzed
II. Ch. 1: the science-based business: a novel experiment
a. Biotech is convergence of 2 separate realms
b. Science biz one that tries to advance sci, not just use it
c. Sci biz needs unique mgmt
d. Sector profits near zero historically
e. Different norms, values, metrics between sci and biz
f. 3 main factors
i. Profound and persistent uncertainty => needs risk rewarding and mgmt
1. Long time horizons for risk to be resolved
2. Appropriability: ability of biz to capture value from an asset
3. Openness vs. secrecy
ii. Complex and heterogenous nature of scientific knowledge => needs integration
1. Cross disciplinary
iii. Rapid progress => cumulative learning
Part 1: The Science of the business
I. Ch. 2: mapping the scientific landscape
a. Locks and keys
b. Random screening
e. combinatorial chem
h. RNA interference
k. Growing size, complexity, heterogeneity
II. Ch. 3: the complex anatomy of drug R&D
a. Can save or kill you
b. So much still unknown
c. So many places where drug can work wrong
d. Target identification and validation: find enzyme
e. Lead identification and optimization: find molecule to inhibit it
f. Preclinical development: check safety and effectiveness before humans
g. Human clinical trials phases 1-3
h. Reg approval
III. Ch. 4: drug R&D and the organizational challenges
a. Not like processor design; very little knowledge about entire system and overall spec
b. Process very complex and can’t be broken into pieces: uncertainty and integrality
c. Most R&D on losers
d. Active ingredient and formulation both matter
e. New scientific advances increase uncertainty; show more what we don’t know
f. More choice means more uncertainty
g. More advances mean harder integreation
Part 2: The business of the science
I. Ch. 5: the anatomy of a science-based business
a. Many separate technologies
b. Cyclical entry
c. Genentech started industry
i. Close links to universities
ii. Biz model innovation: contract w/ big pharma for funding development of drug and royalties in exchange for manufacturing and marketing rights
1. First time pharma did R&D through external for-profit co
iii. Pursuit of broad range of opportunities/diseases
d. Second generation used more chemistry and focused on research, allowing pharma to commercialize
e. Third gen: human genomics, industrialized R&D, platform strategy
f. Market for know-how
i. More collab w/ biotechs than w/ univ
II. Ch. 6: the performance of the biotech industry: promise vs. reality
a. Long lag times
b. Zero industry profits
c. Huge skews for Amgen and Genentech
d. R&D productivity, revenue-adjusted
III. Ch. 7: monetizing IP
a. Txr of IP from univ -> private new firms
b. Capital markets (VC) and public equity
c. Market for know-how (small firms trade IP for funding from big firms)
d. Go public much earlier for funding
i. Only 20% of public co’s today have ANY product on market, so basically R&D entities ) (GAAP not as useful)
e. Univ research -> startup w/ VC -> IPO for more funding -> license to big co to bring to patient
f. 3 requirements for risk mgmt.
i. Many options for diversification
ii. Adequate info
iii. Abilty to reap reward
g. Market for know-how -> integration
i. But biotech less modular and codified than software
ii. IP protection murky
IV. Ch. 8: organizational strategies and business models
a. Few examples of success, high uncertainty, luck plays big role
b. Financing critical for industry and its main measure, but wrong measure because it’s input, not performance
c. Alliances/IP monetization are important but not endgame
d. Movie studio model for big pharma: produce ideas of independent writers
V. Ch. 9: The path ahead
a. Venture philanthropy
b. Rethinking the publicly held biotech firm (doesn’t match 10 year investment cycle)
Some recent interactions with medical researchers and conferences I've attended have caused me to think about incentives in the field of research, and I'm quite worried.
First, I've realized how extremely finicky and sensitive the scientific process is. Final results can be significantly skewed in the "wrong" direction by variations in equipment, ingredient formulations, specific techniques, and parameters used. Many intermediate ingredients (cells, RNA, etc.) are available off the shelf, which seems convenient, but often has the risk of quite variable quality (I personally saw researchers re-ordering some RNA compound because twice they received something that failed to work as advertised).
The scientific process is complex, difficult, and still so labor-intensive. You would think that in the 21st century the "rote" work would all be outsourced to cheaper labor destinations and/or fully automated with machines, but that's still far from prevalent. Science is still being done in many of the most prominent research universities in a form that's closer to high school chemistry than to 2001: A Space Odyssey
Secondly, I've frequently heard about "publish or perish" and the extreme focus on publishing positive, statistically significant results. This makes people care more about quantity than quality and on "proving" hypotheses right rather than disproving them or trying new techniques, even if they don't work. There are no rewards for failure, and you can't get a patent for trying. In professional science, as opposed to school, there is unfortunately no "A for effort." And I think we lose a lot of valuable information and create a lot of wasted time by duplicating techniques instead of sharing with each other by publishing things like, "I tried these 5,000 combinations. They didn't work. So if you read this, you might want to try something else."
This results in several complications to the pure pursuit of knowledge and improvement of the human condition. The best publications are peer-reviewed, and the "peers" are the ones competing with the authors for the same publication slots. The one-way anonymity (not double blind) means that people scratch the backs of their friends and form "societies" (which like to meet at conferences) that are really like old boys' clubs for cheering each other on and publishing each other's work.
Also, the focus on publishing creates so much published research that no one can follow it and keep track of it. I'm always shocked when I see scientific citations listing that an article was on pages 1,056-1,064. Who out there is reading thousand-page long journals? I see the same problem with patents: sure, publishing research and filing a patent make the knowledge accessible (when searching for it) but they don't make it prevalent and don't cue anyone to read the findings by themselves.
In addition, because of the drive to publish quantity and show "results" even when they're suspect, it drives the quality of research down, yielding false results. John Ioannidis at Stanford wrote about how too much medicine relies on flawed assumptions
, explaining how most published research findings are false. The WSJ wrote
explaining how pharmaceutical companies are unable to reproduce most research findings (see above about scientific complexity and sensitivity to specific conditions and compounds).
It's like we're giving people prizes for trying something a thousand times until finally they get lucky enough (or are careful enough) to produce something scientifically significant instead of rewarding them for working hard and producing truthful results (and sharing their experiences either way).
I'm not trying to diss researchers or publications or universities. I know almost all the individuals are honest and extremely hard-working and do believe in the deeper goals of science. I just think the current system is sub-optimal, and I don't know how to fix it. I'm curious to hear what others think.
I finally got a chance to read The Checklist Manifesto
by Atul Gawande and have been talking about it incessantly ever since (along with Daemon
). I found it to be a very well written and interesting account of how checklists can save lives and improve quality across a number of fields. It's something so simple it feels stupid, but people are growing so "expert," overworked, and specialized that checklists are more important than ever to assure quality when it matters.
Below are my main notes and takeaways. I highly recommend this book to anyone interested in efficiency, productivity, and public health. I'm particularly interested in ways to apply the book's concepts to many fields (including starting a business) using technology. Introduction
Ch. 1: Problem of extreme complexity
- Surgeon author's stories
- No one remembered one step of a surgery and caused death
- Great failures and saves throughout his life
- Human fallibility
- Err from ignorance or ineptitude
- Balance recently shifted to ineptitude
- Legal clerical errors
- Training isn't the problem
- Unmanageable amount of know-how
Ch. 2: The checklist
- More than 13000 diseases/wounds
- 6000 drugs and 4000 medical procedures
- Med = art of managing extreme complexity
- Hundreds of diagnoses managed each year on average
- 178 patient actions per day in hospital, errors in 1%
- Have technology to monitor and control all body functions
- Line infections very common
- Super specialization in med
Ch. 3: The end of the master builder
- Pilot checklist
- Too much airplane or medicine for one person to fly
- All or none process: missing one step fatal
- 4 vital signs
- Nursing has adopted checklists but not doctors
- Fixed central line infections at Johns Hopkins
- Dr. Pronovost Initiative
- Keystone Initiative
Ch. 4: The idea
- 3 types of problems
- Simple: like baking cake
- Complicated: like sending rocket to moon
- Complex: like raising child (uniqueness)
- Complex have uncertain outcomes not solved by expertise
- We are besieged by simple problems; checklists help
- Also by complicated problems
- When to follow judgment vs. protocol
- Construction work: complicated
- Evolved like medicine
- But medicine still following "master builder" model which construction evolved beyond
- In medicine, care much less coordinated
- In construction, no margin for error
- Huge checklists and schedules of tasks hanging on walls in modern construction site, coordination across 16 trades
- Daily checks and communications across hundreds of people
- Can't rely on autonomy to deal with complications or unforeseen problems across 16 trades
- Rely on submittal schedule, another checklist
- Communications schedule for who to talk to who about what on which date
- Makes ppl talk on specific dates
- Wisdom of group not individuals
- Man fallible but maybe not men
- Merge all trades' floor plans to find conflicts in software called ClashDetective
- Flags issue for submittal schedule and emails relevant parties to talk
- ProjectCenter software allows anyone on site who spots problem to submit it with digital photo, emails parties, and adds check to schedule for it to be resolved
- Ppl given 3 days to confirm/approve and all tracked
- 5 million commercial buildings, 100 million low rise homes, 8 million high rise residences , in US
- Add 70K commercial and 1M new homes per year
- Very few errors or full collapses
- 20 serious building failures per yr (tiny percent)
Ch. 5: The first try
- Forcing function
- Hurricane Katrina
- Communication breakdown and authority power struggle
- Push power out of the center to the periphery
- Needs different system than command and control
- Walmart stepped up and authorized managers to do what was right
- Efforts to dictate all steps from center fail
- Judgment enhanced by discipline and procedure
- Fine restaurant operations
- Recipes followed exactly and frequently updated
- Daily check meeting in kitchen
- Every plate quality checked
Ch. 6: Checklist factory
- Global surgery volume growing
- 230 mil per year
- Higher death rate
- 2500 different procedures
- 30% don't get properly timed antibiotic
- Pre-incision preflight checklist idea
- Checklist distributes power
- Anyone can stop procedure if not followed
- To deal with unexpected, force ppl to communicate at predetermined time
- Teamwork poor in surgery, unpredictable
- 1 in 8 don't know why doing procedure or where
- Checklist requires ppl to give each other their names
- Reduces nurse turnover and error rate
- Require 3 pause points in surgery
Ch. 7: The test
- Aviation checklists inspiration
- Normal checklist 3 pages plus 200 pages of checklists for non-normal situations
- Do-confirm checklist or read-do checklist like recipe
- Best if 5-9 items like working memory
- Pilot checklist at 3 points of takeoff including communication
- Checklist guided by cockpit computer
- Not meant to be comprehensive just swift help for experts
- In most fields we don't investigate failures because affects one person
- In aviation, failures make news and heavily investigated
- Use flight simulator to test checklist
- Findings incorporated immediately in new checklists and quickly save lives
- In medicine, findings take 17 yrs to be incorporated, huge deluge of medical research
Ch. 8: The hero in age of checklist
- For surgery used do confirm format to give flexibility
- Must disperse authority
- 3 pause points: before anesthesia, before incision, after surgery
- Don't need to mark with check marks
- Had to eliminate a lot of checks to streamline
- Created safe surgery checklist
- 19 checks: 7 before anesthesia, 7 before incision, 5 after
- Did test in 8 international hospitals, very poor and wealthy
- Measured error rates before and after
- Checklist involved culture change
- Start by testing in one OR with senior staff, ppt, YouTube vids
- 3 month pilot study dropped infections and deaths by half
- Mix of ops unchanged
- Hawthorne effect of being observed? No because had been there before started checklist
- Improved teamwork
Ch. 9: The save
- Investors incorporating formal checklists
- Portfolio managers, value investors
- Read broadly, look widely
- When get greedy over good opportunity, need discipline
- Buffett uses mental checklist
- Brain works against you to seduce and make you ignore downside
- Same signals in brain when found profit opportunity as when on cocaine
- Checklist delivers better financial performance
- Avoids risks
- Large resistance against checklists
- VC investment decisions studied
- Checklist driven VCs had better performance
- Feels beneath ppl to use checklist
- Doesn't match idea of heroism
- Hudson miracle due to following procedure
- Saved his patients many times
- Starting a business like construction and medicine
- How can checklists be used
Learnings from Circadian Rhythm Conference
In April, I got the chance to accompany my wife to a conference
on circadian rhythm and metabolic disease (she was presenting a groundbreaking poster on the role of circadian rhythm genes in sebocyte skin cells). The Chancellor of UCLA has a lab studying circadian rhythm science, and I got the chance to hear him speak about his research. The conference took place at the Bruin Woods retreat center in Lake Arrowhead, which was a beautiful location that featured many cool outdoors-y activities like hiking, kayaking, archery, rock climbing, etc. (too bad it wasn't summer time!), and the food was really good too.
While most of the talks were highly technical, I was able to follow some of them and learned a lot about the importance of the circadian rhythm in affecting practically all biological functions. On the flip side, I learned how irregularities in one's rhythm can disrupt and cause many common diseases, especially diabetes (irregular rhythm is stronger indicator of diabetes than weight/BMI!). What that means for you: go to sleep on time to stay healthy!
From an "eastern medicine" standpoint, these findings make sense, as the circadian rhythm is what allows us humans to stay in sync with nature around us. And I can see how in our 24/7, work-a-holic, always-online world, circadian rhythms and "synchronization with nature" can get more easily disrupted.
Below are some of the main lessons I took away from the conference sessions. Here's a recent WSJ article
on the topic as well.
- Circadian rhythm regulated by SCN part of brain (across 2 hemispheres)
- 80,000 neurons stay in sync!
- VIP synchronizes, GABA desynchronizes
- Circadian rhythm expressed in most major organs (pancreas, liver, skin)
- Light from eye comes in and gives signal to brain
- Experiments use rat models, fat mice, skinny mice, mice with clock genes knocked out (poor mice!)
- Measure mouse activity by "wheel running" (funny concept; I tried to ask why mice like to run on the wheel but couldn't get a clear answer)
- Clock genes expressed in cells
- Bladder shrinks during the day and grows at night to enable comfortable sleep (cool!)
- Shift workers have higher risk of cancer (!!)
- Melatonin is protective of cancer (and bad circadian rhythm messes up melatonin)
- Messed up circadian rhythm leads to diseases (diabetes, hypertension, metabolic syndrome)
- Messed up circadian rhythm is a stronger indicator of diabetes than BMI (!!)
- High fructose corn syrup (like in soda) lowers mental function in mice
- Bad circadian rhythm + bad diet increases hypertension risk
- Circadian rhythm disturbance leads to metabolic disorders because of dyssynchrony between what body programmed to do and what body does (not in harmony with nature)
- Exercise at specific times on a daily basis can fix a broken circadian rhythm (used timed wheel access for mice)
- Circadian disorders affect memory and learned behavior
- Aging clock: reduction in wheel running amplitude in old mice
- Old adjust more slowly to new light schedules
- Phase advance forward increases mortality for old animals (eastward travel) but phase delay back doesn't (if you're old, try not to fly east!)
- Cool concept: "social jet lag" (going to sleep late Friday and Saturday is like flying west and then waking up early Monday is like flying east)
This is a talk I gave at UCLA for our first-year communications class. It was inspired by stories I heard from my parents as well as my own personal experience watching my wife go through medical school. You can check out the PowerPoint via SlideShare below.
Libby Zion was an 18-year-old freshman girl who had just started attending college in New York in 1984. She was admitted to the hospital with a high fever, and the only physicians who saw her that night were doctors in training known as residents, who had been working close to 36 hours straight and were busy with dozens of other patients. There were medical errors committed along the way, and within 24 hours of being admitted to the hospital, Libby was dead, and her family was mortified.
Our current system of medical education is extremely suboptimal and urgently needs to change for the benefit of both patients and doctors. Why should you care about this problem that is rarely discussed? Sooner or later, you and your family are bound to get sick, and your lives will be in the hands of physicians out of your control. For instance, I’ve learned from my wife who is a medical student that June is the most dangerous month to go to the hospital because all of the residents and med students are brand new and are getting their first chance to “treat” real patients.
The main counterarguments that aim to keep the medical training system as it is are a tradition of hazing new doctors, keeping costs down by employing fewer doctors, and allowing doctors to have continuity of care for patients without switching off too much, but I will demonstrate from the perspective of patients and doctors that these benefits are not worth their extreme costs. Though some changes have been made to reduce doctor hours to 80 per week with no more than 36 hours in a shift, further changes are still necessary because the problems for patients and doctors remain severe.
The current medical training system is extremely dangerous for the patients it is ultimately trying to serve. When you consider the biggest causes of death on an annual basis (according to an Institute of Medicine report), the top four are the usual suspects: heart disease, cancer, stroke, and respiratory disease. But what’s shocking is that the fifth worst cause of death is medical errors, accounting for almost 100,000 deaths each year and costing our economy almost $20 billion, more than diabetes and Alzheimer’s. While most of the other causes of death are natural and hard to avoid, medical errors are by definition preventable. Research studies have shown that well-rested residents outperform tired residents on memory skills, interpretation of scans, and monitoring of patients, and doctors attribute more than half of their mistakes to sleep deprivation and having too many other tasks to do.
In addition, a recent study in Nature magazine showed that after 24 hours of wakefulness, cognitive function deteriorates to a level equivalent to having a 0.10 blood alcohol content, 25% higher than the legal limit for driving. If we don’t let people drive their cars at that level, why are we letting them operate on our loved ones?
But driving is not the only serious problem for doctors; in fact, it is just one of several severe risks the current medical education system presents for doctors just like it does for patients. According to an article in Academic Emergency Medicine, ER residents are seven times more likely to have a motor vehicle accident due to falling asleep at the wheel during their residency than before it. Not only are doctors physically in danger with the current system, they are also mentally suffering and losing their caring attitude towards patients. A recent New York Times article compared the suicide rates of doctors with the general population. The article showed that the suicide rate was 40% higher for male doctors and a staggering 130% higher for female doctors than general population. The most concerning piece of evidence, though, related to the training system’s effects on doctors comes from a study that reviewed real journal entries of residents. One journal entry stuck out but was representative of many other entries just like it: “It’s 1:00am, and I'm ready to go to bed when there's a code blue. Probably a nice man with a loving wife and concerned children, but I don't want him to live if it means I don't sleep. I just want to sleep.” It goes without saying that if the sleep deprivation is bringing individuals who swore the Hippocratic Oath to such a desperate, inhumane mental state, something is terribly wrong with the training system.
Therefore, in order to produce better outcomes for patients and help lower the thousands of deaths due to medical errors like Libby Zion’s as well as to create more safety and caring attitudes for doctors, we need to improve the medical training system by reducing the number of hours doctors work and increasing the amount of supervision. There is plenty of demand to go to medical school, so it is simply about hiring slightly more doctors. There will already be plenty of need for more doctors with universal healthcare coverage and increased healthcare demand. What all of you can do about this important issue is to help publicize the problem and get the word out about it, such as through blogs and talking to any journalist friends you might have. In addition, by writing to your Congressmen and voting on issues related to medical training, you can help to change the system one day.
But until that time, don’t go to the hospital in June.