RoS: Review of Systems

This week, we are discussing a recent article from the journal Drug and Alcohol Dependence, entitled: Association between process measures and mortality in individuals with opioid use disorders, by Katherine Watkins and colleagues: Susan Paddock, Teresa Hudson, Songthip Ounpraseuth, Amy Schrader, Kimberly Hepner, and Bradley Stein. We are also joined by a guest discussant, Gabriel Wishik. Gabriel Wishik is a clinician educator in general and addiction medicine, and is an instructor at Boston University and Boston Medical Center. He is the clinic medical director at Boston’s Healthcare for the Homeless Program’s largest clinical site and practices harm reduction in primary care with a population at the front lines of the current opioid epidemic. You can find the obituary we shared on the show here. If you like the show, please rate and review us on itunes, google play, stitcher or your favorite podcasting app, which makes the show easier for others to find; and share us on social media. We tweet at @RoSpodcastand are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you. This interview has been lightly edited for length and clarity. This podcast was initially published on 8/29/17.

Dr. Scott Stonington is a medical and cultural anthropologist – and an internist. He studies decision-making at the end of life in Thailand and spent many years accompanying Thai patients at the end of life and in particular trying to understand pain, suffering, and the role of pain medications from these patient’s points of view. Dr. Stonington also studies medical epistemology in the U.S., specifically looking at how health practitioners decide what constitutes true and/or useful knowledge and how this affects patients. Please read his Perspective in the New England Journal of Medicine about the concept of the debt of life, The Debt of Life – Thai Lessons on a Process-Oriented Ethical Logic, and his article in JAMA entitled Whose Autonomy?, a meditation on how he thinks about decision-making, pain, and pain control. In addition, he wrote further about how his work in Thailand has changed his thought process on pain in The (f)utility of pain, published in the Lancet. Also, a quick note that the day we recorded this show I was still recovering from an upper respiratory infection and you can hear me coughing which is distracting so I apologize about that. If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening. This interview has been lightly edited for clarity (and Audrey’s terrible voice this week!). Photo courtesy of Scott Stonington.

  Dr. Annie Brewster found herself frustrated as a primary care physician. There simply was not enough time to hear her patients’ stories and feel that she got to know them. Her belief in the meaning of stories and the healing power of narrative, as well as her own experience as a patient after a diagnosis of multiple sclerosis, have animated her career, as she went on to found an organization, the Health Story Collaborative. The Health Story Collaborative aims to collect, share, and honor stories of illness and healing, with the goal to create a forum for story sharing to make the process of navigating illness less isolating, and to empower individuals and families facing health challenges. Annie joins us today to talk about her career and the healing power of narrative. Dr. Brewster regularly writes for WBUR’s Commonhealth Blog, and you can see her talk about her work here. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening. This interview has been lightly edited for length and clarity. Portrait courtesy of Dr. Brewster, credit John Soares.

Over the last 25 years, CareMore health has been a leader in innovative care models for chronic disease. The company serves 100,000 patients in 8 states through Medicare Advantage programs and more recently expanded into Medicaid. CareMore particularly aims to take on patients with chronic disease through an intensive, high-touch care program. Today, Sachin Jain, CareMore’s president and CEO joins us to talk about CareMore’s model, their approach in joining new markets, their outcomes, and their unique programming aiming to reduce loneliness among their members. You can find the Commonwealth fund article we discussed here, and Sachin’s article in Forbes here. Also, we previously did a journal club about CareMore’s collaboration with Lyft to improve transportation to appointments – you can find that here.  Sachin H. Jain, MD, MBA is chief executive officer (CEO) at CareMore Health, an innovative healthcare delivery system with $1.2B revenue & over 100,000 patients in 8 states.  He is also a consulting professor of medicine at the Stanford University School of Medicine and a contributor at Forbes. Dr. Jain was previously CareMore’s chief medical officer (CMO) and chief operating officer (COO). Prior to joining CareMore Health, Dr. Jain was Chief Medical Information & Innovation Officer at Merck & Co. He also served as an attending physician at the Boston VA-Boston Medical Center and a member of faculties at Harvard Medical School and Harvard Business School. From 2009-2011, Dr. Jain worked in the Obama Administration, where he was the senior advisor to Donald Berwick when he led the Centers for Medicare & Medicaid Services (CMS). Dr. Jain was the first deputy director for policy and programs at the Center for Medicare and Medicaid Innovation (CMMI). He also served as special assistant to David Blumenthal when he was the National Coordinator for Health Information Technology. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

This month’s journal club, we discuss the article Medical Legal Partnerships At VA Medical Centers Improved Housing and Psychosocial Outcomes for Vets  by Jack Tsai, Margaret Middleton, Jennifer Villegas, Cindy Johnson, Randye Retkin, Alison Seidman, Scott Sherman, and Robert A Rosenheck. David Rosenthal and Audrey Provenzano are joined by the lead authors of the study Jack Tsai and Margaret Middleton. If you would like to learn more about medical legal partnerships, please review the website of the National Center for Medical Legal Partnerships. If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

This week we are featuring a reprise show with Bon Ku, the Assistant Dean for Health and Design and an Associate Professor at the Sidney Kimmel Medical College at Thomas Jefferson University, to talk about design thinking and medicine. Bon is a practicing emergency medicine physician and the founder and director of JeffDESIGN, a first-of-its-kind program in a medical school that teaches future physicians to apply human-centered design to healthcare challenges. Bon has spoken widely on the intersection of health and design thinking (TEDx, South by Southwest, Mayo Clinic Transform, Stanford Medicine X, Association of Collegiate Schools of Architecture) and serves on the Design and Health Leadership Group at the American Institute of Architects. Bon talks with us about what design thinking is, how he got into it, why he thinks physicians would benefit from learning to think in this way, and how to apply it to common primary care challenges, like walk-ins. He also directs listeners to the following resources to learn more about design thinking in medicine: the Stanford Dschool, and ideou. If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

The opioid epidemic is the greatest public health crisis of our time. It is estimated that about 64,000 people died of opioid overdoses in 2016 – more than died in the Vietnam war or in 1 year at the height of the AIDs epidemic. Dan Ciccarone, our guest this week, and a Professor at UCSF School of Medicine, has spent his career trying to improve our understanding of substance use disorders and their health consequences. He and his collaborators look at this question both up-close, through ethnographic research in the community, and hours and hours of interviews with people who use injection drugs, and also by stepping back and sifting through huge datasets, looking at the larger epidemiologic and economic forces shaping the epidemic. He has spent years studying heroin specifically, and is currently the PI of the Heroin in Transitions study, which continues this vital work. We talk specifically about a study led by one of his collaborators, Dr. Sarah Mars, “Every ‘Never’ I Ever Said Came True”: Transitions from opioid pills to heroin injecting; his group’s study of trends in hospitalizations and what that tells us about the epidemic in a 2013 Plos One publication, Intertwined Epidemics: National Demographic Trends in Hospitalizations for Heroin- and Opioid-Related Overdoses, 1993–2009. We also discuss his recent look at some of the larger factors influencing the epidemic with collaborators Nabarun Dasgupta and Leo Belitsky in Opioid Crisis: No Easy Fix to Its Social and Economic Determinants. You can find more information about the book Dr. Ciccarone mentioned, Dreamland by Sam Quinones, here. And you can find the American Society for Addiction Medicine’s waiver training here. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening. This interview has been lightly edited for length and clarity. Photo courtesy of Dr. Ciccarone.

“How do we get the data and the information necessary to address health?” In this episode, another in a series with speakers from the 2017 second Starfield Summit, we talked with Dr. Andrew Bazemore about how primary care occupies the juncture between public health and health care. Andrew believes achieving health equity necessarily involves harnessing the democratization of data by pairing aggregated population health data to patient data in EHRs. We talked about his vision of Community Vital Signs and the challenges to getting there; the legacy of Sidney Kark, H. Jack Geiger, Gene Farley, and Curtis Hames and how they would drool at modern geographic information systems; how Community Vital Signs could help triage patients and help them achieve better health; and the potential for ecological fallacy in the work. Andrew Bazemore is a practicing family physician and the Director of the Robert Graham Center, which he joined in 2005. He oversees and participates in the Center’s research with a particular interest in access to care for underserved populations, health workforce & training, and spatial analysis. He has authored over 150 peer-reviewed publications, while leading the Center’s emphasis on developing tools that empower primary care providers, leaders, and policymakers.  He also serves on the faculties of the Departments of Family Medicine at Georgetown University and Virginia Commonwealth University, and in the Department of Health Policy at George Washington University School of Public Health. He is an elected member of the National Academy of Medicine(NAM), and appointed member of the federal Council on Graduate Medical Education (COGME). The Starfield Summit brought together leaders in primary care, clinicians, experts, advocates, patients, and community members in 2017 to collaborate in paving paths towards health equity and social accountability. The Summit was primarily sponsored by FMAHealth, OH&SU, and OCHIN.  Stay tuned in upcoming weeks for more speakers from the Starfield Summit. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at thomasATrospod.org. We’d love to hear from you, and thanks for listening. This interview was edited lightly for length and clarity.

These days, we hear about social determinants of health constantly – more of us are screening for social needs in our clinics and payers are searching for effective ways to address them as an avenue to improve outcomes and ideally reduce costs. Dr. Laura Gottlieb, a family physician and researcher at UCSF joins us today to talk about her research, which focuses on evaluating interventions to identify and address social factors in health care. You can find many of Dr. Gottlieb’s publications here, as well as the Health Affairs blog post by Drs. Toyin Ajayi and Iyah Romm mentioned in the podcast. You can also use this link to the SIREN website to find more resources on the intersection of social and medical care. A little more about our guest: Dr. Gottlieb is Associate Professor of Family and Community Medicine at the University of California, San Francisco and director of the Social Interventions Research and Evaluation Network (SIREN). Dr. Gottlieb’s current research focuses on evaluating interventions that identify and address social factors as part of health care delivery. These interventions include volunteer-powered social services Help Desks, payment reforms that support social programs, and other efforts that support responding to patients’ social needs in medical practice, like re-designing electronic medical records to incorporate social determinants data. Dr. Gottlieb also is an Associate Director of the Robert Wood Johnson Foundation Evidence for Action National Program and was a co-founder of HealthBegins, a non-profit organization providing education, consulting, networking, and technology services to health care providers interested in joining the effort to move medicine upstream. Prior to her current appointment, Dr. Gottlieb was a Robert Wood Johnson Health and Society Scholar at UCSF/UCB. She completed her MD at Harvard Medical School and both her MPH and residency training at the University of Washington. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at 

For this week’s journal club, David, Thomas, and Audrey bring listeners short overviews of three articles. Audrey discusses an article published in the journal Pediatrics Dec 18 2017, called Exemptions from Mandatory Immunization After Legally Mandated Parental Counseling by Saad Omer, Kristen Allen, DH Chang, Beryl Guterman, Robert Bednarczyk, Alex Jordan, Alison Buttenheim, Malia Jones, Claire Hannan, Patricia deHart, and Daniel Salmon. David chats about the Dec 14, 2017 commentary published in New England Journal of Medicine by Dr. Lisa Rosenbaum entitled The Less is More Crusade – Are we Overmedicalizing or Oversimplifying. And Thomas shares a Health Affairs article, Government spending health and nonhealth sectors associated with improvement in county health rankings, published in their November 2016 issue. If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

How can we use tech to make healthcare better and more accessible? Dr. Nwando Olayiwola, a family physician, faculty member at UCSF, and Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers, has spent many years thinking about that question. She joins us this week to tell us about her career in primary care, tech, and leadership. We also discuss her powerful essay, Racism in Medicine: Shifting the Power, and her research looking at various aspects of tech and care delivery. Thank you to the Harvard Center for primary care for helping to facilitate this interview. I did make a few recording snafus on this interview – so my apologies for the sub-optimal audio quality in a few sections. A little more about our guest: Dr. Nwando Olayiwola is a family physician and the inaugural Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers. She is also currently an Associate Clinical Professor in the Department of Family and Community Medicine at University of California, San Francisco. She served as the Director of the UCSF Center for Excellence in Primary Care until February 2017. In that role, she supported the Center in achieving strategic objectives around primary care transformation and systems redesign regionally, nationally and internationally. Prior to her work at UCSF, Dr. Olayiwola served as the Chief Medical Officer of the largest Federally Qualified Health Center system in Connecticut, Community Health Center, Inc. (CHCI), where she developed expertise in medical administration, translational and implementation research, professional development, systems based and quality improvement and practice transformation of twelve primary care practices into Patient-Centered Medical Homes. Her work led to CHCI being one of the first organizations in the United States to receive both the NCQA Level 3 PCMH and Joint Commission PCMH Recognitions. She has been a leader in harnessing technology to increase access to care for underserved and disenfranchised populations and is an expert in the areas of health systems reform, practice transformation, health information technology and primary care redesign. She is on the advisory board of Primary Care Progress and the Robert Graham Center for Family Medicine and Primary Care Policy. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening. This interview has been edited for length and clarity.

This week, we are joined by Dave Chokshi. Dave is the Chief Population Health Officer of OneCity Health and Senior Assistant Vice President at New York City Health + Hospitals—the largest public health care system in the U.S. He practices primary care at Bellevue Hospital and is a Clinical Associate Professor of Population Health and Medicine at the NYU School of Medicine. We talk about what population health is, how it is distinct from public health, and what value it adds to our healthcare system. We also talk about how in some ways it might contribute to the erosion of relationships between primary care providers and patients, how that can be remedied, and how the small 1 or 2 doctor practice may fit into a population health management vision. We talk about a piece he wrote with Neil Calman and Diane Hauser about what they call the “expanded denominator,” and how that may further goals of public health and accountable care. Lastly, we talk about population health approaches in urban and rural settings, and how we should think about the opioid epidemic from a population health vantage point. We reference a few articles throughout our conversation: Christine Sinsky’s already classic Annals paper detailing that physicians spend two hours on administrative tasks for every hour they see patients, and our journal club on that paper. Robin Williams’ and colleagues Health Affairs blog on utilizing the HIV cascade of care to battle the opioid epidemic, and Lawrence Casalino and colleagues work calculating what we spend measuring the care we provide. In addition, we reference the Surgeon General Vivek Murthy’s landmark report on addiction. A quick note about a word we use frequently but didn’t pause to define for listeners – attribution. Attribution is the assignment of a specific patient to a specific primary care physician in a health system. Once a patient is attributed to a PCP or health system, that PCP and health system is held accountable for the patient’s quality measures and healthcare costs within ACOs or other alternative payment contracts. This still applies patients who do not frequently access the healthcare system through traditional channels or most frequently see specialists, who perhaps have never seen the assigned PCP, and is therefore at times controversial. A little more background on Dr. Dave Chokshi: He was Assistant Vice President of Ambulatory Care Transformation at NYC Health + Hospitals and director of Population Health Improvement at NYU School of Medicine. In 2012-13, he served as a White House Fellow at the U.S. Dept. of Veterans Affairs, where he was the principal health advisor in the Office of the Secre...

This episode starts with a question: “what if the architectural design of an obstetric unit influenced the c-section rate in that unit?” That question occurred to obstetrician/gynecologist Neel Shah when he attended a presentation by Michael Murphy, the co-founder and executive director of Mass Design, an architectural design and research firm that focuses particularly on healthcare architecture. Neel thinks about c-section rates all the time and is a leading researcher in the field of maternal health. C-section rates vary widely throughout the US – from 7 to 70%, and where a woman delivers better predicts whether she will get a c-section than her own personal risk factors. So, Michael Murphy’s contention that “Architecture is never neutral. It either heals or hurts” stayed with Neel and inspired him to pursue a research initiative between Mass Design and his research group, Ariadne Labs. Neel Shah and two of his collaborators, Amie Shao and Deb Rosenberg, researchers and architects with Mass Design, join us to talk about their collaboration and the report they produced. Amie Shao is a director with MASS Design Group, where she oversees research focusing on health infrastructure planning and evaluation. In addition to guiding impact research for MASS built projects, she coordinated the production of National Health Infrastructure Standards for the Liberian Ministry of Health and has been involved in the design and evaluation of healthcare facilities in Haiti, Africa, and the United States. Deb Rosenberg joined MASS in 2015, with a unique background in healthcare and architecture. Throughout her career in nursing and architecture is a common ambition to promote health and well-being, and she believes that the spaces where people live, work and heal have the capacity to greatly support or restrict our human potential. Neel Shah, MD, MPP, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and director of the Delivery Decisions Initiative at Ariadne Labs. His team is currently collaborating with hospitals across the United States, and using methods from design, systems engineering, and management to reduce the epidemic of avoidable c-sections. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Thomas Kim, David Rosenthal, and Audrey Provenzano discuss a recent article from the American Journal of Public Health called Community Health Worker Support for Disadvantaged Patients with Multiple Chronic Diseases: A Randomized Controlled Trial, by Shreya Kangovi, Nandita Mitra, David Grande, Hairong Huo, Robyn Smith, and Judith Long. This important work comes from researchers associated with the Penn Center for Community Health Workers. You can find more about the research here, and more about Dr. Kangovi, the lead researcher on the study, here. Dr. Kangovi also recently penned an article in Stat News reflecting on the meaning of her research, which you can find here.  If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

In order to make primary care better, we have to understand what is working and what isn’t – and not just in broad strokes, but in granular detail. Dr. Christine Sinsky is on the cutting edge of this type of research, and publishes prolifically on what is driving burnout in primary care, what specific steps we can take to fix it, and how to return joy to practice. Dr. Sinsky is the VP of Professional Satisfaction at the AMA and has practiced as a general internist for 30 years in Dubuque, Iowa. We talk about her landmark work with Tom Bodenheimer, which introduced the idea of the quadruple aim in 2013, how new EHR metrics can improve how we deliver care and improve the experience of caregivers and patients, and the extent of the burnout crisis in medicine at large, not just primary care. You can find the call for research that Dr. Sinksy referenced and collaborated on with Dr. Lotte Dyrbye and other leaders in this field here. We previously featured one of Dr. Sinksy’s publications, which showed that physicians spend about 2 hours doing clerical work for every 1 hour they see patients in a journal club, which you can find here. If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening. This interview has been lightly edited for length and clarity. Photo courtesy of Christine Sinsky.