Simplicity through Innovation

A friend who is also involved with the International Rescue
Committee, told me about solar phone chargers that also
work as lights. They are being sold and distributed in the third
world and refugee camps as a solution to lack of electricity. A
portion of sales in the US are used to subsidize affordable prices
for the product in the third world. The product is called Waka
Waka (which means light in Swahili). I immediately
ordered one from Amazon ($65), and I am enthralled. Not only did
the device come in a simple cardboard sleeve (no plastic!) the
instructions were all diagrams. After leaving it in my window sill
for a few hours, I hooked my 30% battery smart phone up through a
USB cable and watched as it recharge it completely in about 15
minutes! The device is design at its best: simple, durable,
elegant. My experience with the Waka Waka has ignited my thoughts
about how we can bring these elements to health care. Like the Waka
Waka, techniques and practices that have been developed for places
with few resources, are now being eyed by those in the US not only
as a way to contain costs, but also to achieve better outcomes. For
example, recent press about heart
surgery in India has the attention of doctors, policy
makers and payors in the US and Europe. Simplicity can take on many
different meanings when it comes to health care, from simplifying
medication regimens, to coordinating care and health information
technology. However, the goal should be a happier, healthier and
more satisfied patient population. As we think about the future of
US healthcare, lets think Waka Waka: Let there be LIGHT! -Jennifer
Brokaw, MD

Our Narratives Through Change

“Everything I’ve ever let go of has claw marks on it.” – David Foster Wallace

 Our youngest daughter just graduated 8th grade, and I am really trying not to leave claw marks on her elementary school.  After a total of eleven years there, I’m finding it difficult. First, I am going to miss the familiar faces, rituals and exceedingly pleasant atmosphere in the place. But more significantly, I am finding it difficult to accept that we don’t have young children anymore, and therefore, I must rewrite my inner biography.

Until recently, my narrative involved being a mother to two daughters who needed lunches made, permission slips signed and endless rides to school, soccer, chorus or social activities. I was the woman of the household, the caregiver, but also the one who might get admiring looks from strangers when I dressed up. Now, I am a supervisor who asks that my charges “check in and let me know when you get on the bus”, and when I get looks from strangers, I quickly realize they are actually looking at one of my beautiful daughters. Truth be told, this is not the first time I’ve changed my narrative, but it’s one of the times that I am not completely happy about the plot-line.

This realization has made me ponder the transitions I witness others make all the time at work. As a physician and patient advocate, I am called in when someone has gone from being someone “in perfect health” to someone with cancer, or from being an independent survivor of the Great Depression and WW2, to a person with Alzheimer’s who needs assistance with the most basic functions.  These are not the narratives we want to write. In fact, I remember riding on a crowded elevator with a client who was going for her first chemotherapy session at a cancer center. Someone broke the silence: “Cancer is for the birds” they said. My client replied: “No kidding!” In that moment, her narrative changed from self-pity to solidarity, and she was able to confront her new chapter with resolve rather than resignation.

When the narrative takes on a dark or less-than-heroic turn, our defenses go up and we fight the inevitable. Sometimes it’s in the form of denial (is that why I forgot to buy tickets to the graduation or get teacher’s end-of-year gifts?) and other times it’s overt hostility. Ask any geriatrician what their least favorite task  is, and two out of three will respond: “Taking the keys away”. However, with a little “creative writing”, these moments don’t always have to be so difficult. In one memorable instance, a family member conjured up a very large “repair bill” for his father’s car hoping his father’s Depression–Era frugality would trump his desire to keep driving. By allowing his Dad to “decide” to forego the repairs and find more economical ways to get around, he maintained his narrative as a practical decision maker even in the face of dementia.

Admittedly, sometimes the narrative is impossible to sugar-coat. There are some diagnoses that don’t allow for much hope or “up-side”.  It is in precisely those moments that we must allow the person to salvage as much of their narrative that they can. Talking to patients early on about what’s to come and what to expect is the only way they can write their own final chapter. Without that knowledge, their story might end in the hospital when they really wanted it to be at home, or as the center of a family feud instead of the peace maker.  What I’ve come to learn is that there is always the opportunity to help the dying write their narrative if we give them the chance—and even if the narrative isn’t exactly what they would otherwise choose,  the ability to influence even small aspects of it is very powerful.

            It is with that perspective that I face this small change in the narrative of my life and ask myself how I can turn what seems to be a bittersweet transition into a joyful one. Observing my young women engaged in the wider world is really enough to make it all right, but reconnecting with my husband who has been on the work/parenting treadmill with me for the past sixteen years is an opportunity I cannot pass by.  I am determined that the three day road trip with him while the girls are off being their independent selves this summer be one funny and juicy chapter in my life story.

-Jennifer Brokaw

June 2013

Crazy for Coconut Oil?

Coconut oil: Is it too good to be true?

What is it? Coconut oil is an edible oil extracted from coconut meat.Most commercially available coconut oil isrefined or “partially hydrogenated”. It is extracted from dry coconut meat and treated with high heat and chemicals.

Virgin coconut oil, on the other hand is extracted from fresh coconut meat and is not chemically treated.

The cure? The information about coconut oil is confusing at best. As a health food there are claims that it helps thyroid disease, heart disease, obesity, diabetes, Alzheimer’s disease and many other conditions. Recent video testimonials are compelling. What do we know about these claims? Very little. There are few good studies on coconut oil and disease outcomes. The best studies are on the short-term impact of coconut oil on cholesterol levels.₁ Unfortunately we do not know about its long-term effects or its effects on heart disease. The findings are interesting but there is still no clear answer to the question of harm or benefit.

 The concern: Coconut oil contains 92% saturated fat.₁ This is more than butter (64% saturated fat) or lard (40% saturated fat).₄ Processed or “partially hydrogenated” coconut oil additionally contains trans fats (bad fats).₃ These fats are associated with heart disease and this type of coconut oil is unhealthy.

 On the other hand, virgin coconut oil is not partially hydrogenated and does not contain trans fats but it still contains 92% saturated fat. This is worrisome for many since saturated fats are considered less healthy and can raise your LDL (bad) cholesterol. Conversely the oil may also increase “good” HDL cholesterol levels.₄

 Considerations: Do not use refined or partially hydrogenated coconut oil.Virgin coconut oil is a better choice since it does not contain trans fats (bad fats).

Fats in moderation are an important component of a healthy diet. Limit your saturated fats to less than 10% of your total calories.₂ Use coconut oil (92% saturated fat) sparingly as it is also high in calories. One tablespoon of coconut oil contains 117 calories, 14 grams of fat, 12 grams of saturated fat and no vitamins or minerals.₁

As a food, virgin coconut oil is very interesting. It has a slightly sweet, nutty, coconut flavor that enhances pastries, cakes, frostings, sautéed vegetables, roasted sweet potatoes, etc. Unlike other vegetable based oils, it is a solid at room temperature and a liquid when heated. Due to the saturated fats it has qualities a lot like butter or lard. It is very stable and can be stored at room temperature for 1 to 2 years without going rancid. Check out a tasty coconut oil recipe for a chocolate ice cream topping created by Thomas Keller a renowned chef and restaurateur. http://www.nytimes.com/2011/03/02/dining/02apperex4.html

 The debate about the benefits and risk of coconut oil continues. The scientific evidence does not support the health claims yet. We will know more in the future but in the meantime, as with many things: moderation is the key!

 

1.      Zelman K; The Truth About Coconut Oil; WebMD Web Site; http://www.webmd.com/diet/features/coconut-oil-and-health; March 10, 2011; Accessed May 22, 2013.

2.      Nutrition and healthy eating; Mayo Clinic Web Site; http://www.mayoclinic.com/health/dietary-guidelines/MY01594; Accessed May 22, 2013.

3.      Maloof R; Coconut Oil; MSN Healthy Living Web Site; http://www.healthyliving.msn.com/diseases/cholesterol/coconut-oil-1; Accessed May 21, 2013.

4.      Willit W; Ask The Doctor: Coconut Oil; Harvard Health Publications Harvard Medical School Web Site; http://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2011/May/coconut-oil; May 2011. Accessed May 21, 2013.

 By Alicia Sakai, PharmD

May 23, 2013

 

15 Questions for a Concierge Physican Practice

Considering changing to a Direct Pay/Concierge or Boutique Physician? Because there is a shortage of primary care physicians, and primary care has suffered declining reimbursement rates from insurers, Direct Pay Medicine is a growing trend. However, because it’s relatively new, there is a striking lack of standardization in pricing or types of services offered. Here are come suggested questions to ask when interviewing a concierge physician:

Fees:

1. Do you charge annually or monthly? (Are all office visits covered in that fee?)
2. Will you help submit claims for all non-covered services to my insurance?
3. Will you see me if I am in the hospital? (Is there an extra charge for that?)
4. Do you participate in Medicare?

Services:

1. Do you make house calls?
2. Can I get a same-day appointment?
3. Do you offer email communication?
4. What is included in an Annual Visit (ie. what tests are performed and what counseling will I receive?)
5. Do you have an area of specialization? Do you have a sub-specialty Board Certification?
6. Do you have other physicians in your practice? Nurse Practitioners? Physicians Assistants? What role do they play in your practice?
7. Are there specialists (Cardiologists, Endocrinologists, Othopedic Surgeons) that participate in your concierge practice? Will they give me preferred access?

Philosophy:

1. What is your attitude toward Complementary and Alternative Medicine, CAM (acupuncture, homeopathy, naturopathy eg)? Are there practitioners of CAM that your regularly refer to?
2. What wellness or preventive services do you offer?
3. Will you guarantee to continue to care for me even if I develop a serious illness? (corollary: are there any conditions under which you would dismiss me from your practice?)
4. What is your philosophy about hospice? Will you care for me until the end of my life?

Can you think of any other important questions? If so, please feel free to share them in the Comment box below.

Re-Making Advance Directives

On April 16th,  we honored the sixth National Healthcare Decision Day (NHDD). NHDD was established with the goal of increasing the number of people who have Advance Health Care Directives (only 30% of Americans have one) and increasing communication about health care wishes to loved ones and health care providers.  However, in order to achieve those goals, we must re-think the Advance Healthcare Directive altogether and engage the health care system in a new paradigm.

    As it stands now, an Advance Directive legally designates a health care agent (someone who will make decisions for you if you are mentally incapacitated). Most form Directives also ask whether you would want to receive CPR if your heart stopped, and whether or not you wish to be an organ donor.   Unfortunately, those limited instructions do not cover the majority of health care decisions, and place an undue burden on the person named as agent. For example, the desire not to receive CPR does not inform doctors or family members about a desire for emergency surgery when the outcome is uncertain.

People I survey casually about Advance Health Care Directives say they have completed theirs with an attorney, in the form of a Living Will. Because it is written by an attorney, a Living Will is often not written in language that is helpful to physicians, containing vague terms like “terminal” and “vegetable”.  Although it’s better than nothing,  in my twenty years in medicine, I have seen a patient’s Living Will in a hospital chart only once or twice.  Furthermore, most physicians I know are not likely to follow a lawyer’s pro-forma instructions when delivering critical care. The other time people create Directives are when they are being admitted to the hospital, and is a result of the Patient Self Determination Act, passed in 1991. Needless to say, the hospital admissions desk is not an ideal time to create a Directive. Furthermore, there is evidence that Directives as they are written today, are not very effective in the hospital. A study in 1996 showed that simply having a Directive-even when there was an effort to convey its content to physicians, did not reduce ICU stays, number of people put on life support or pain experienced by patients. (1) Sadly, it doesn’t appear that much has changed since then. (2) There are many reasons for this, but I believe that that is largely a reflection of the typical Directive itself, which should be reconsidered entirely. 

On the other hand, a good Advance Care Plan is done with a medial professional and anticipates some medical decisions based on particular health history. It also reflects your values and priorities, and most importantly, expresses the overall goals you have for your quality of life.  A well-written Advance Care Plan can give loved ones and doctors a blueprint to discuss critical decisions about life sustaining treatment, facilitating a dialog that is much more meaningful than “Should we perform CPR?”. It is not surprising that it has been shown that families that have undergone Advance Care Planning have significantly less prolonged grief and increased satisfaction with the health care system after the death of a loved one in the hospital. (3)

To be sure, this is not an easy task and requires special skills, training and significant time to accomplish. To that end, it will require a commitment of resources. Although it will also require a change in mind-set for physicians and hospital administrators, I believe the medical profession must commit to creating better Directives and make a pledge to improve adherence to Directives when patients are unable to speak for themselves. I am glad we now have a National Health Care Decision Day, but without physician’s and hospital’s participation, nothing much will change for patients at the end of life.

References:

(1) http://www.ncbi.nlm.nih.gov/pubmed/7474243

(2) http://www.ahrq.gov/news/newsletters/research-activities/jul12/0712RA10.html

(4) http://www.bmj.com/content/340/bmj.c1345

Dr. Jennifer Brokaw is the Founder of Good Medicine, a private practice specializing in patient advocacy and Advance Care Planning.