Takin’ It To The Streets

For those who can’t read that headline without thinking of the Doobie Brothers, click here and you should get a little Spotify popup to listen to while you read.

It’s time, I think, to start talking about what I’ve been doing with myself for the past couple of weeks, mostly because I’m getting increasingly pumped about the progress that I’m making. For those that don’t know, I’m in the process of trying to open a whole food plant-based restaurant in Saint Paul. I could just say a vegan restaurant, but it seems that many people are scared by “vegan food“. So, when I come up with the perfect name for the place, we’ll call it a plant-based eatery and not use the scary “v” word. On that note, if anyone has any great name ideas, please pass them along!

So, I have a concept for a fast-casual plant-based eatery that serves beer, wine, coffee drinks and desserts as well. I found a location that I think is ideal not too far from where I’m now living. The place is a dump at the moment, but it has amazing potential. The owner is pretty chill and we’ve come to terms on the lease, which is currently under legal review, but looks good. I have found a construction company that specializes in urban restaurant’s and they are hot for the project. I even have an architect/design team that seems really cool and has done some great work. It would seem, then, that I need a chef!

Oh, wait, I’ve got one of those too! I found Rick Berdahl as a result of a CraigsList post I made looking for a vegan chef. It turns out that I got 18 people to respond to the ad in about a week. I interviewed 7 and Rick has a great complimentary skill set and we seem to share a vision of what this place can be. So we are working on a menu now and will pick that up over the next couple of months.

Now, however, is the daunting part. It’s the part that seems to stymie the majority of people who are interested in getting started in the restaurant business; money. Fortunately, I have two things that most of them don’t. The first is an MBA degree (from the University of St. Thomas). This taught me the importance of writing a solid business plan, which I did. Not like it’s going to win any awards, but it’s a decent piece of work. The second is a decent savings plan. I had my third meeting in almost as many days with a commercial loan banker this morning and I’m hopeful that sometime in the next week or two I’ll be able to tell you that I’m funded and moving full steam ahead. If that happens soon, I hope to be open around October 1.

Stay tuned for more and do pass on name ideas. Currently I’m favoring Cecci (chech-ee; italian for chickpea), but I’m not sold on it.

My 15 minutes…

MCC & HCMC

A lot of people know the Andy Warhol quote that in the future everyone will be famous for 15 minutes. It turns out that (of course) Andy Warhol probably didn’t even say it, but that’s not really the point. It was a crazy day yesterday and quite unexpected. But first, a little backstory.

After I quit practicing medicine and was just starting with the social media scene I came across an organization called the Physicians Committee for Responsible Medicine (PCRM). I noticed that a lot of the posts they had on Facebook and Twitter were really well aligned with how  I was thinking and I was surprised that: 1) I’d never heard of them before (but they are based in Washington, DC) and 2) I was not aware that there was a politically active group pushing lifestyle medicine. For those not familiar with the term, lifestyle medicine is about finding health through diet and activity rather than pharmaceuticals and surgery.  Or, as the Institute of Lifestyle Medicine puts it:

The Institute of Lifestyle Medicine (ILM) is at the forefront of a broad-based collaborative effort to transform the practice of medicine through lifestyle medicine. This critical transformation is motivated by research indicating that modifiable behaviors — especially physical inactivity and unhealthy eating — are major drivers of death, disease, and healthcare costs. While the medical profession is generally aware of this, there has yet to be a systematic and comprehensive effort to incorporate lifestyle medicine into standard practice. We accomplish this by providing professional education focusing on knowledge, skills, tools, and clinician self care and by creating resources for patients.

What I liked about PCRM is they are very active not only in the politics of moving this agenda forward, but also very active in doing research to prove the benefits. So I joined the PCRM and, being a guy with a bit more free time than most docs, I offered to help in any way possible.

Fast forward to early April, when I got an email from PCRM telling me that they had discovered that Hennipen County Medical Center (HCMC) is one of the few places that is using animals (sheep and rabbits) for training their Emergency Medicine residents. PCRM has an ongoing survey of medical teaching institutions in the US and has found that only 12% still use animals to teach procedures; most have moved away to human simulations like SimMan. PCRM had been in communication with the Emergency Medicine residency program and had asked them to quit using animals and, instead, use HCMC’s “Interdisciplinary Simulation Center”, which is capable of simulating all of the procedures for which they are using animals. When HCMC didn’t agree to stop using animals, PCRM filed a complaint with the Animal and Plant Health Inspection Service, a branch of the Department of Agriculture that oversees the use of animals for testing and teaching. In the complaint, PCRM pointed out: 1) HCMC’s justification for animal use is insufficient because alternatives exist, 2) the use of sheep and rabbits for Emergency Medicine training is not “unavoidable” and 3) the Minneapolis Medical Research Foundation failed to properly oversee this use which violates the Animal Welfare Act. The PCRM was asking me, then, to join the complaint as a physician from Minnesota and told me that it was likely I would be interviewed by the media when the story came out.

Yesterday, the story came out. I was sitting around, minding my own business yesterday morning when I got a call from the PCRM office in Washington, DC. The story had broken and they were getting calls from some of the media outlets in the Twin Cities. Would I be available to discuss later in the day? I’ll spare you the details of the multiple phone calls and emails to coordinate, but I learned that there are some really crappy jobs out there and Dania DePas from PCRM has one. It was barely controlled chaos for a while.

First I got a call from Youssef Rddad (Re-dodd) from the Minneapolis Star Tribune. Youssef is a student at the U and works in a “student reporter” role at the paper. Obviously I was not a high priority. I talked with him on the phone for about 20 minutes yesterday afternoon. He hadn’t read the complaint, didn’t really have any idea what was going on or why he should care. I spent most of the time getting him on track. I then emailed Dania from PCRM and asked her to forward as much information to Youssef as she could. Apparently he also talked to Dr. John Pippen, the director of Academic Affairs (and author of the complaint) at PCRM. The end result of that work can be seen here, in today’s Star-Tribune article. I was surprised that the finished article was as cogent as it turned out to be.

Off the phone with Youssef and I needed to find a place to sit down with KARE 11. Fortunately, the “Club Room” at my apartment building was free and the staff didn’t mind me using it spur of the moment. I donned my suit and met a cameraman/reporter from KARE 11. He set up his camera and I got mic’ed up and he sat across the table from me and asked a couple of questions. He had not read the complaint either. He wasn’t exactly sure what the issues were and didn’t have much of a plan for the “interview”. It lasted about 10–15 minutes and was pretty anticlimactic for what you’d anticipate being interviewed by TV news would be. Just as he was finished, WCCO arrived. I’m not terribly surprised that KARE 11 didn’t air it nor does it appear on their website. I think they got out what they put into it, very little.

The experience with WCCO was entirely different. Let me say, from the outset, I am impressed. Bill Hudson, a staff reporter came with a cameraman. I got a different mic on and we sat in the same places that I had with KARE 11. Mr Hudson had, however, read the complain, made some notes and highlighted some passages. In other words, he was prepared. We chatted for a few minutes while the cameraman got set up, mostly background stuff. He then asked a number of questions and pretty gently led me through it. All in all we probably spent 20–25 minutes talking to get the few seconds of TV time that occurred. You can see the spot here.

I’ve never been interviewed by TV before. Unfortunately, I have spent a little time in depositions and in court and I did a surgical residency in the late 80’s and early 90’s, so I’m accustomed to being asked to explain myself. Nonetheless, I admit that I actually watched the news yesterday, which is something I haven’t done in forever. Nothing on the 6 pm news, but I was amazed to find the story as the lead on the 10 pm broadcast on WCCO. OMG. Moreover, I was quite impressed at the balance that Mr. Hudson got on the story, managing to use the PCRM complaint, my interview, some discussion of simulation training, and HCMCs statement. I thought it was an excellent job.

So that’s it. My 15 minutes of fame on TV. Dania tells me that KMSP/FOX, who had arranged an interview yesterday, but cancelled at the last moment, may want to do something today, but I suspect the story has hit it’s peak and will slide into obscurity for now. But was fun and I’d definitely do it again.

Let’s talk about food

One of my recent pet peeves is the concept of “vegan food”. I keep hearing that over and over and it’s starting to make me a little crazy. When omnivores talk about “vegan food” they say it like it’s something a little strange. But really, it should only take a moments reflection to realize the truth. Food is food. Everything that we put in our mouth to eat or drink is food. If you go out to a steak place and order whatever hunk of cow or pig you choose to eat, but decide to have a piece of bread first, do you stop to think of the bread as vegan? Of course not, you slather it up with butter and call it a warm up to the meal. But if you chose to forgo the butter or used a non-dairy spread, would it somehow morph into “vegan bread”? Or how about that salad before the meal. Does the fact that you’re eating a salad at a steak house seem incongruous to you? Is it weird that you’d enjoy something that any vegan might enjoy before you eat your meat? The last time that you ate a piece of fruit, did you stop and ponder that you’re eating “vegan food”? Of course you didn’t. And that’s the very point. Food is food is food. The difference between omnivores, vegetarians, vegans, paleos, or whatever isn’t what we eat, it’s what we choose not to eat.

If you’re an omnivore, you choose to forgo only those foods that you find unpalatable, for whatever reason. Even when I was an omnivore I didn’t eat liver, the taste and texture where not at all to my liking. And I’ve never cared for fish or seafood. For whatever reason, for me it all tastes like a fish market smells and I think everyone can agree that isn’t good.

But now I’m a vegan and the only thing that’s changed is that I decided to stop eating animal products. I still eat food. I still eat much of the same food that you eat, if you’re not a vegan. The only difference is that I have chosen not to eat the things that are demonstrably unhealthy for me, are disruptive to the planet’s climate and perpetuate a culture of brutality and cruelty to beings that are unable to defend themselves. OK, maybe the first part of that statement isn’t really true, but it leads me to the next point.

Just as there is no such thing as “vegan food”, there is no such thing as “healthy food”. Food is either nutritious or not, but there is nothing about food that is inherently health promoting. Health is achieved by eating the right amount of nutritious food and getting some exercise. Eating too much is unhealthy. Eating food that has little to no nutrition is unhealthy. Sitting all day in front of a computer is unhealthy. And any combination of the last 3 is very unhealthy, with the worst being all 3 combined. But you already knew that, didn’t you?

 

 

U.S. Healthcare: A Kobayashi Maru

For those somehow unfamiliar with the term, The Kobayashi Maru is from the Star Trek universe and is an exam giving to Star Fleet Academy cadets. It exposes the cadets to a no-win scenario to test their problem solving under pressure. This no-win scenario is precisely what has become of healthcare in the United States.

The numbers on this should be reasonably familiar to anyone who is paying attention at all. Like this graph from The Commonwealth Fund showing that US Healthcare is 17.1% of our (very large) Gross Domestic Product (GDP – the total value of all goods and services produced in a country over the course of a year) compared to an average of 10.6% for other “developed” countries.Squires_OECD_exhibit_01

But, with all that spending, we must be getting something really great, right? Maybe it’s because we have so many doctors, or we go to see the doctors so often. Nope, that’s not it.

Squires_OECD_exhibit_03The same study shows (above) that the US has among the fewest practicing physicians per 1,000 people of population and a fairly low number of physician visits per year.

Well, maybe our health care is so expensive because we have more hospital beds or more hospitalized patients. Again, no.

Squires_OECD_exhibit_04As you can see, we are again below average in the number of hospital beds and the number of hospital discharges.

OK, it must be the doctors. The doctors are really raking it in and that’s our high cost of health care in the US, right. And again, nope.

DoctorPayThis graph, from Forbes in 2013 is especially interesting. It appears, from the first column, that US physicians are quite overpaid in comparison to other developed countries, averaging almost twice the pay. But, as the article points out, that’s not an “apples to apples” comparison. The US has about 30% primary care physicians and about 70% specialty physicians, a ratio that is almost opposite all of the other countries surveyed. Specialists earn, on average, more than primary care docs, so the concentration of higher earning specialists in the US skews the overall averages. Column 2 is the ratio of earnings of specialists to GDP per capita and it is still above other countries, but not as much as the combined specialists and primary care docs. Column 3 compares the earnings of specialist physicians to “high earners”. The article explains: “the more relevant comparison is not to the average worker but to members of the talent pool from which American physicians are recruited. When specialty earnings are compared to those of high earners—i.e., those in the 95-99% of the earnings distribution—it turns out that physicians in nearly all other countries, not just the U.S., are paid reasonably well“. By this same comparison, US primary care docs are slightly underpaid, but not grossly so.

OK, we don’t have more doctors or visits to the doctor. We don’t have more hospital beds or patients in the hospital. Our doctors are not really grossly overpaid and certainly not to the extent to explain our wildly out of line health care costs. It must be that we’re just getting better care, right? Sadly, this is not true either.

TCFchartThis chart from a Forbes article (reporting on The Commonwealth Fund‘s article) shows that US healthcare ranks 11th out of the 11 countries surveyed. Most worrisome, at least to me, are the last three measures; Efficiency, Equity, and Healthy Lives, where we rate dead last. Efficiency scored poorly because: “The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of administrative hassles, avoidable emergency room use, and duplicative medical testing.” We are last on equity because: “Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick; not getting a recommended test, treatment, or follow-up care; or not filling a prescription or skipping doses when needed because of costs. On each of these indicators, one-third or more lower-income adults in the U.S. said they went without needed care because of costs in the past year”. And we rated last on Healthy Lives because: “The U.S. ranks last overall with poor scores on all three indicators of healthy lives—mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60″.

Note that the actual cost of services isn’t really discussed. But, as reported by PBS, the prices for many common procedures is higher in the United States compared to other countries. But, like with physician pay, the magnitude here is not enough to explain the huge discrepancy. US_prices_for_certain_procedures_are_much_higher_slideshowSo what is going on? How did our health care costs get so out of line and why, if we pay so much, so we get such poor care and leave so many people without care? The answer, I believe, is two-fold. First, the simple answer is profit. Second, we’ve lost sight of our priorities.

Let’s look at profit, first. Many of the countries named thus far, besides the US, have nationalized health care. That is to say that all citizens of those countries receive health care as a part of the rights they have for being citizens. Of course it is funded through taxation and many countries offer additional perks for those with the money to buy them. But everyone gets healthcare. The United States health care system is, of course, based upon profit. Physicians have been given an incentive to do more because doing more means getting paid more. Hospitals were given incentive to provide more services because they were able to make more money. It was not some evil conspiracy that created this, it’s just the way our system evolved. On the flip side, we have evolved private insurance companies who are given incentive to provide as little care as possible for those that buy their insurance because doing so maximizes the profit for the shareholders of the companies. And make no mistake, if you’re looking for the biggest hoard of money in medicine, look no further than health care companies. The revenue of the top 5 insurance companies in the US for 2014 is illustrated below. That’s about $350,000,000,000.

insurance profitsThat represents a lot of profit. And don’t think that just because you live in a state like Minnesota (like I do) where health care insurance is mandated to be provided by not-for-profit companies that they aren’t raking in the money. The St. Paul Pioneer Press reported that in 2012 the HMOs in Minnesota had cash reserves of $1,900,000,000. Yes, that’s 1.9 billion dollars. With cash reserves of $1.9 billion I have a heard time understanding why health insurance premiums in Minnesota rose, in 2014, 19% when the cost of living increased less than 3%. Did the cash reserves need to get bigger? And out of Minnesota, if United Health Care is earning around $5,000,000,000 in profit each year, why do their health insurance premiums keep going up? The answer is that UnitedHealth is not in the business of taking care of patients, it’s in the business of making money for it’s shareholders. And it’s all about profit.

Let’s take a minute to look at priorities. Obviously, the priorities for profit is a problem, but it’s not the only problem. Back to those that actually provide care to people, doctors and hospitals. First, they still get paid, to a large extent, by what and how much they do. There is a movement to slowly change the system to pay for outcomes (i.e. pay for keeping people healthy), but it will take a very long time for this to become the norm. A large amount of the payment that doctors and hospitals receive is also based upon “patient satisfaction” or HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems). But does anyone see the fundamental flaw in asking patients about their experience of care? What if the care you received was first rate, but it wasn’t what you wanted to hear? Who rates their experience of finding out they have cancer, heart disease, diabetes, or any other serious disease as good? And if your doctor came to your bedside and told you that you had bad heart disease and you needed to immediate adopt a low fat vegan diet if you wanted to live, would this be a good experience for you? What if you had successful triple bypass surgery? That might be good, but it hasn’t addressed the issues that clogged your vessels in the first place and it won’t really extend your life, but you feel like something good has happened and will probably relate that as a good experience. And now you’re just as much a part of the problem.

So what can be done to fix this depressing health care mess? Honestly, I don’t know. All I can do is take care of myself as best as possible. For me, that means a vegan diet. Actually, for most people that means a vegan diet, but I can’t make you eat right any more than I could get you to exercise regularly, quit smoking, quit drinking to excess or any of the other lifestyle choices that make such a difference. But I do know that if we don’t figure out a way to rein in our health care costs, it will be nothing but trouble in the future.