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Mistreated

Metadata

  • Author: Robert Pearl
  • ASIN: B01LL8C2IM
  • ISBN: 1610397657
  • Reference: https://www.amazon.com/dp/B01LL8C2IM
  • Kindle link

Highlights

among developed countries, the United States has the highest infant mortality rate, the lowest life expectancy, and the most preventable deaths per capita. — location: 57 ^ref-59869

As a nation, we spend 50 percent more on medical care than any other country, and yet we rank seventieth globally in overall health and wellness. — location: 60 ^ref-10635

We pay US physicians far more to intervene during a heart attack than to prevent one in the first place. — location: 61 ^ref-43563

We have the best-trained doctors on the planet, and yet their avoidable mistakes kill nearly 200,000 Americans each year. — location: 61 ^ref-6411

as consumers, we demand the latest technologies from our banks, telecom providers, and retailers, but we passively accept last century’s technology in our hospitals and medical offices. — location: 62 ^ref-48592

Why do smart people do dumb things in their jobs, relationships, and everyday lives? — location: 65 ^ref-10778

Scientists have demonstrated that under the right conditions, our brains undergo a shift, causing us to perceive the world around us in ways that contradict objective reality. — location: 67 ^ref-40380

our health care system functions in an environment unlike any other. There’s nothing comparable to it in American culture, society, or industry. The rules are different, the stakes are elevated, and the perceptions of everyone in it—from doctors to patients to US presidents—get radically distorted, leading to behaviors that prove hazardous to our health. — location: 70 ^ref-49124

If character flaws were the central challenge facing American medicine, the solutions would be much simpler. We would select different medical students and isolate the sociopaths. But health care’s most common failings aren’t individual. They’re contextual, systemic, and therefore much more problematic. — location: 82 ^ref-51092

the intersection of business and health care. — location: 92 ^ref-27611

Two features, however, were out of proportion, both with clear intent. First, David’s head is notably oversized, signifying the importance of discernment and choice as he sets out to face the biblical giant Goliath. Second, his hands are huge, a nod to the importance of action. — location: 103 ^ref-998

As individuals and as a nation, we need to see what is happening, decide to do something about it, and take action. — location: 105 ^ref-45293

It’s amazing how quickly time moves when you’re the doctor providing care. And it’s eerie how slowly time passes when your father is the patient, and all you can do is watch and wait. — location: 152 ^ref-24280

I was jolted by the realization that these well-trained physicians from renowned academic programs seemed content to rely on the memory of a man in his seventies to tell them what kinds of medications he was taking and the exact dosages. — location: 216 ^ref-37518

A great example of contrast providing clarity.

A patient with his spleen removed, for example, is at risk of developing severe infection. — location: 231 ^ref-11550

One specific bacterium that’s particularly problematic for people without a spleen is the pneumococcus. Without a spleen to filter this pathogen out of the bloodstream, the pneumococcus can infect a patient’s entire body. — location: 232 ^ref-57182

every person whose spleen has been removed should receive a pneumococcal vaccine. — location: 235 ^ref-31624

My dad’s doctors in New York assumed the ones in Florida had given him the vaccination. The physicians in Florida assumed the ones in New York had done so. The medical specialists believed the surgeon who removed my father’s spleen had administered it. And all the specialty physicians thought my father’s internal medicine doctor had taken care of it. In the end, no one had. — location: 237 ^ref-23633

On most visits, my father’s physician needed only to assess the wound and make sure it was healing properly. For that, my sister could have visited our dad at night, taken a digital photo of his foot, and e-mailed it to the doctor for thorough review at her convenience. I doubt this idea ever crossed the doctor’s mind. Physicians are not trained in medical school to worry about the inconveniences they place on patients or their families. And in their practices, they find that insurance companies are rarely willing to pay for the kind of “virtual visits” that would have saved my sister more than a hundred hours of missed work. — location: 265 ^ref-24022

One morning, a driver rear-ended his car. My father suffered severe and disabling back pain. To provide relief, his doctors recommended a series of cortisone injections around his spinal cord. To prevent bleeding from the injections, they took him off the anticoagulation medications he was on for his atrial fibrillation. Before he could complete the series, he suffered a massive blood clot in his brain. — location: 274 ^ref-13831

Good ex. 4 need 4 more specific antithrombotics

when there were no more suggestions to be made, no procedures left to recommend, the doctors stopped coming altogether. From that moment on, we never saw another physician in our father’s room. No one came by to check in on the family or ask how we were doing. None of his doctors dropped in to offer a word of support. I felt abandoned by these healers in our time of greatest need. — location: 284 ^ref-17544

Throughout much of history, there was little doctors could do to help their patients. They simply lacked the tools, medications, and knowhow we have today. Perhaps that’s why doctors of the past became such skilled practitioners of empathy and compassion. — location: 287 ^ref-29876

Doctors get paid for intervening, not for moments of compassion. Today, the insurance reimbursement system dictates how care is delivered. It has eroded personal relationships, devalued empathy and kindness, and undermined the very mission and commitment that led most doctors to practice medicine in the first place. — location: 292 ^ref-21627

US health care trails almost every other industry in the adoption of information technology. — location: 305 ^ref-41477

fewer than 15 percent of all patients can use e-mail with their doctors, and even fewer can review their own medical information online or schedule a “video visit.” — location: 306 ^ref-49422

once all Americans begin to see the true problems endemic in our health care, and once we understand the threat they pose to our families and ourselves, we will demand change. And once enough people do, we can reverse the damage, for good. — location: 320 ^ref-17479

physicians perceive anxiety as deriving from the individual, not from the individual’s situation. They fail to recognize the fear and anxiety that patients experience every time they go to see a physician. — location: 1043 ^ref-16980

Rarely do the consequences of having to miss school or work enter the doctor’s consciousness or affect clinical decision making. — location: 1047 ^ref-41408

But Dr. Greene knew that part of being a physician meant improving people’s lives, not just treating their physical problems. — location: 1077 ^ref-21287

During the moments in between, Felipe holds his granddaughter in his arms and sings her Spanish lullabies, imagining the life that awaits her. — location: 1092 ^ref-49503

The reality is that today’s health care delivery system is not designed around your time or priorities. It is designed to maximize the productivity of doctors. And as the physician’s reimbursement rates continue to decline, and as insurance companies continue to refuse to pay for virtual care, none of this is likely to change soon. — location: 1110 ^ref-37149

No, the coat lengths were designed to establish relative authority among doctors. In the same way that stripes and stars on military uniforms communicate rank, the length of a doctor’s coat establishes to what degree his or her opinion matters. In medicine, long-standing traditions continue far beyond their logical utility, evidence that health care is influenced as much by culture and past norms as by science. — location: 1125 ^ref-29707

Even today, we rely on the practices and rituals of yesteryear. — location: 1188 ^ref-53581

As patients, we expect our doctors to have access to high-powered machinery that can heal us in times of crisis. But at a subconscious level, we also expect the hands-on rituals of the past. We want our medical care to be both “high tech” and “high touch.” Both have become health care’s table stakes. — location: 1199 ^ref-29663

Perception is rarely objective and data based. It reflects the context of our environment and is altered by anxiety, fear, and reward. And when our perception changes, we unknowingly act in ways that seem irrational to outside observers. — location: 1208 ^ref-31162

When smart people with access to clear data make foolish decisions, all signs point to a subconscious shift in perception. In this case, we can best ascribe the selection to “anchoring bias.” — location: 1262 ^ref-56152

But when something seems logical, our brains tend to believe that it’s true, even when the scientific data say otherwise. — location: 1276 ^ref-59733

Our perceptions (those of both doctors and patients) are that more care is better care. — location: 1279 ^ref-39378

American health care is the auto dealership of the past, void of the transparency, technology, and consumer control we value today. And most of us just accept it. — location: 1307 ^ref-63023

we tend to worry more about events we hear and read about in the media and our social networks than those that are actually the most dangerous. — location: 1318 ^ref-7571

we likewise focus on data breaches, which are important and worrisome. And yet we pay little attention to medical errors that result from a lack of data. — location: 1322 ^ref-37661

Physicians today aren’t so direct or compassionate. — location: 1382 ^ref-11304

Patients who are given palliative, supportive care instead of suffering through another round of chemotherapy report that their final days are less painful and more fulfilling. — location: 1390 ^ref-61564

Quality outcomes today rarely reflect individual physician ability, but rather the performance of the entire team providing medical care. — location: 1413 ^ref-15325

Success is determined much more by whether doctors are reimbursed for the quality of their outcomes or the quantity of the procedures they perform. This context shapes not just doctors’ perceptions but also their clinical performance. — location: 1420 ^ref-43299

by picking the best system (based on these reports), patients will be much better off than when they try to identify “the best” individual doctor for their problems. — location: 1444 ^ref-2580

The pharmaceutical world is brilliant at shaping perception through rewards that fatten wallets and stroke egos. — location: 1456 ^ref-51866

It is estimated that for every $1 a pharmaceutical company invests in marketing, it earns $10 in return. — location: 1461 ^ref-9026

Insurers know that you have an option to select a new health-insurance policy every year, but that you will most likely make the same choice year over year. — location: 1476 ^ref-62872

subconscious fears and what’s called prior-decision bias, — location: 1480 ^ref-55092

With prior-decision bias, we hold tight to our choices, valuing the things we chose (like a coffee mug) more than the other options available to us. — location: 1480 ^ref-16778

The medical care we receive and our perception of its quality are greatly affected by others. In fact, the influence of some of health care’s biggest players, from insurance companies to drug manufacturers, contributes greatly to the problem and has serious negative consequences for us as well. — location: 1496 ^ref-4362

But when you are that large and successful, you are convinced your viewpoint is truth no matter what. — location: 1540 ^ref-65427

more than 30 percent of all US government spending goes to health care—a combination of Medicare, Medicaid, veterans’ care, marketplace subsidies, and medical research. — location: 1558 ^ref-41903

US health care accounts for 18 percent of every dollar Americans spend. — location: 1576 ^ref-15340

traditional approaches they believe have worked for decades. They argue that Americans need more, not fewer, prescription drugs, medical devices, high-priced health insurance plans, and invasive procedures. And with their massive profits, media platforms, and lobbying influence, the views of legacy players have become our nation’s collective reality. — location: 1579 ^ref-50330

If you’re an elected official, you may care about all the people you serve, but you care the most about those who increase your chances of getting reelected. — location: 1585 ^ref-54033

That’s simply the mindset necessary to run for and stay in office. If you were in that same context, you would see that people who show up at the polls are seen as more important than those who don’t. You would perceive those who can deliver entire voting blocs as more important still, and those who make the largest campaign contributions as most important of all. Citizens who do none of those things would likely get pushed to the periphery. — location: 1587 ^ref-23436

a decision worthy of a detailed water-composition analysis that never took place. — location: 1604 ^ref-13941

it is very difficult to imagine they would consciously choose to ignore the data and harm the children of their community. But it’s not at all difficult to imagine that these politicians simply couldn’t see what they were doing in the context of this developing financial crisis. — location: 1611 ^ref-38393

For elected officials, votes influence how they view the world and determine what is most important. — location: 1626 ^ref-35939

For traditional legacy players, money is the most influential and important element. — location: 1627 ^ref-7886

But to truly understand the factors shaping American medicine, both now and in the future, you’ll need to understand health care’s legacy players better. — location: 1633 ^ref-54827

Major insurers. — location: 1635 ^ref-55527

Hospitals. — location: 1640 ^ref-19465

community hospitals are the second-largest source of private-sector jobs. — location: 1640 ^ref-60133

Community hospitals account for more than 30 percent of all health care costs in the United States, driven in no small part by inefficiencies in the way they deliver care. — location: 1642 ^ref-65438

Physician specialty societies. — location: 1643 ^ref-60631

There are about 200,000 primary-care physicians in the United States. That’s a lot of doctors. But in the pecking and economic order of American medicine, they exert very little influence. By contrast, the American societies for cardiology, orthopedics, oncology, and other high-cost specialties have a huge impact. — location: 1644 ^ref-24114

Drug and device companies. — location: 1647 ^ref-19883

the design and economics of the American health care system reflect their influence. — location: 1653 ^ref-60225

The Implicit Association Test, or IAT, can be taken online by those interested in learning more about their own hidden biases relative to gender, race, sexuality, age, or physical appearance. — location: 1662 ^ref-57331

it’s not a question of what we think, believe, or decide, but what we actually experience. — location: 1697 ^ref-22313

England and Canada, the government controls both the financing and certain aspects of health care delivery. — location: 1703 ^ref-35760

Australia, Sweden, and Germany, medical care is publicly funded, though in large part it is privately delivered. — location: 1704 ^ref-35854

organized medicine and the specialty organizations of that era predicted such a move would undermine the excellence of American health care and lead to socialized medicine. — location: 1709 ^ref-21016

But when the expansion in coverage brought them new patients and added income, their perceptions changed and they warmed up to the idea. — location: 1710 ^ref-1816

But the biggest issue for our nation isn’t who funds it. In reality, it doesn’t make much of a difference whether the funding is paid directly through employers or via government taxes. The iceberg that awaits is the total cost of providing care. — location: 1741 ^ref-23242

You might think that with their power and market clout, insurance companies would be able to restructure US health care delivery. However, historically, these “payers” have had very little influence over the provision of care. It’s not that they don’t want to improve performance at the care-delivery level. They just don’t know how. — location: 1745 ^ref-29168

To insurers, money and financial incentives are the solution to every problem. — location: 1748 ^ref-64866

doctors get accepted into medical schools by doing well on tests. Pay for performance is just another test. — location: 1752 ^ref-13252

pay-for-performance system. Rather than focusing on the proper indications for the screening tests (that is, which patients would benefit from them), doctors started ordering them for everyone, in order to collect the financial reward. — location: 1759 ^ref-63079

in parallel, the doctors stopped focusing on the important preventive interventions that weren’t being rewarded. — location: 1762 ^ref-56950

You might assume that a 90 or 95 percent MLR would signal great success, as it would mean more money was going toward improvements in quality and patient health. But insurance company executives are rewarded and their stock prices rise the fastest when their ratio is as low as possible. — location: 1767 ^ref-30367

“cherry-picking” and “lemon-dropping.” — location: 1772 ^ref-46329

The goal for insurers was to maximize profits by (1) encouraging relatively healthy people (cherries) to join a health plan, and (2) discouraging relatively sick people (lemons) from seeking coverage under the company’s plan. Insurers accomplished this by denying coverage to individuals with preexisting conditions and by denying reimbursement for as many health care services as possible, including maternity care. — location: 1774 ^ref-30511

health insurers switched tactics in 2014 and began offering subscribers “narrow networks.” These new coverage options offer lower premiums in exchange for a reduced choice of care providers, anywhere from 30 to 70 percent fewer in-network physicians. — location: 1777 ^ref-49740

Theoretically, insurers could use this added influence to obtain concessions from doctors and hospitals that lead to greater savings for policyholders. More likely, they will try to use the reduced competition to charge higher premiums for businesses and individuals. — location: 1790 ^ref-32707

Through the lens of the major insurance companies, their job is to calculate risk and price plans accordingly. And from their perspective, the rising cost of health care is hardly their fault. — location: 1795 ^ref-32933

when you see health care as a privilege, not a right, you dismiss the financial challenges of those without coverage, deride universal systems, and scoff at how long it takes citizens in other countries to obtain routine procedures and tests. — location: 1806 ^ref-24989

the issue is not whether one perception is right and the other is wrong. It’s a matter of how we see that world. — location: 1808 ^ref-12342

Cooperation and concern for the well-being of others makes for a powerful societal norm, which in turn has made the Swedish health care system both high performing and incredibly safe for patients. — location: 1821 ^ref-60661

Working together, physicians, nurses, and hospital leaders analyze data on clinical outcomes to determine the best approaches for all patients. They translate these practices into consistent pathways that all physicians follow, scrutinizing them down to the smallest detail. — location: 1824 ^ref-61333

By elevating the performance of every doctor to match the best, the entire hospital achieves superior outcomes at lower costs. — location: 1829 ^ref-40518

the Swedes figure which is actually the best, and they purchase it in higher volumes at reduced prices. — location: 1832 ^ref-43999

In American medical culture, doctors in hospitals perceive variation in practice as a positive, not a problem. — location: 1834 ^ref-55761

Our doctors spend hours each month reading the latest medical journals and insist that research studies should be scientifically controlled and subject to statistical analysis. Then when it comes to their own practices, they resist the idea that there is a best approach and that every doctor should adhere to specific evidence-based best practices. — location: 1836 ^ref-4677

Physician Specialty Societies — location: 1857 ^ref-5545

two objectives: advancing clinical practice and advancing the financial success of its members. — location: 1860 ^ref-31381

US primary-care organizations recommend men without symptoms skip the PSA test. Some even point out the many ways the test leads to more harm than good, including higher risks of infection, impotence, and incontinence from the resulting surgery. — location: 1867 ^ref-47282

Several large studies have shown that the operation, plus physical therapy, is no better than physical therapy alone. — location: 1874 ^ref-62934

Through the lens of people who are paid to maximize the income of orthopedic surgeons, the specialty association leaders simply couldn’t see what other experts in their field were able to identify so easily. — location: 1882 ^ref-20187

The fee schedule (a complete list of fees used to pay doctors/hospitals) aligns with this hero status, reinforcing the perception that intervening during a crisis is more difficult and more valuable than preventing one. — location: 1893 ^ref-59769

residency programs have been federally subsidized through Medicare, with few additional investments coming from elsewhere. And in the United States, hospitals receive the same financial reimbursement from the government whether they train primary-care physicians or orthopedic surgeons. — location: 1905 ^ref-47820

To a hospital administrator, training a resident in a surgical specialty is almost certain to positively affect the hospital’s bottom line, whereas the financial impact of adding another primary-care resident will be minimal. — location: 1912 ^ref-56789

Ask health care leaders about primary care and all will agree: we have a national shortage and should train more. They’re right. But when they have the opportunity to hire and train more of them, that’s usually not what they choose to do. — location: 1913 ^ref-16924

Any hospital executive who decides to consolidate and send his or her facility’s heart-surgery patients five miles up the road would be fired for undermining the medical center’s brand. It would be the right move for the patients and the community, but it would be a career-ender for the CEO. — location: 1922 ^ref-19063

the best predictor for higher volumes of surgery in a given geography isn’t the rate of disease but the number of surgeons practicing there. — location: 1949 ^ref-24761

We need to shift more dollars from specialty to primary care. Of course, that’s not how the specialty societies and their members perceive the situation. — location: 1957 ^ref-61324

In the past six years, the average price for the most widely used brand-name drugs in the United States has increased 128 percent. — location: 1969 ^ref-46062

though prescription-drug coverage blinds most Americans to these astronomical fees, insurers pass along the costs to patients through higher premiums, deductibles, and copayments. — location: 1970 ^ref-42258

because of the rapid rise in health care costs, hourly wages for US workers have remained relatively flat over the past two decades. — location: 1972 ^ref-16046

Because our government is legislatively prohibited from negotiating or regulating prescription prices and because such countries as Canada, Spain, the United Kingdom, and the Netherlands have government agencies that do, US payers and patients contribute to a disproportionately higher share of drug-company profits. — location: 1973 ^ref-26737

Patent laws are designed to encourage research and development and to reward companies that take risks. Increasingly in the drug world, they do neither. — location: 2001 ^ref-18031

That’s a 2,500 percent return on investment, essentially guaranteed and relatively risk free. — location: 2011 ^ref-19399

Pharmasset radically changed the prognosis for patients with chronic hepatitis. — location: 2013 ^ref-62564

Gilead used its size, power, and patent protection to extract exorbitant profits from insurers and patients. — location: 2013 ^ref-44498

drug spending through Medicare increased by $17 billion from 2013 to 2014. Almost 20 percent of that was because of Sovaldi. — location: 2014 ^ref-47808

over the past decade, there has been a fundamental shift in the drug industry. Rather than focus on major R&D investments to address the most severe problems patients face, they are using acquisition, patent protection, and price escalation to fatten their balance sheets. — location: 2032 ^ref-7560

central to their marketing efforts is shaping perception through persuasive advertising messages. — location: 2034 ^ref-43413

drug companies went heavy on direct-to-patient advertising. — location: 2038 ^ref-11130

They knew that most of the time when patients request a new brand-name medication from their doctor, they get it. — location: 2038 ^ref-15741

Take, for example, the promise and hype surrounding the “surgical robot.” — location: 2055 ^ref-29027

Each arm has a built-in obsolescence factor that forces hospitals to replace them after ten uses. — location: 2063 ^ref-57543

there’s little evidence that using them more than ten times poses any risk to patients. However, once the manufacturer slapped a warning label on the device, no hospital in America would risk using the arms eleven times. — location: 2065 ^ref-56809

Doctors decide what devices they’ll use, and hospitals get to decide how much extra to bill for the technology. And in general, insurance companies pay up, then raise their prices the next year to compensate. — location: 2078 ^ref-1524

What few realize is that the most successful pushers in history are drug companies and doctors. — location: 2083 ^ref-9649

Studies conducted in the late 1980s and early 1990s confirmed that health care providers were, in some cases, undertreating pain. — location: 2098 ^ref-36655

through continuing-medical-education programs and meetings — location: 2100 ^ref-20148

the United States consumes over 80 percent of the world’s most addictive oral pain pills and 99 percent of its hydrocodone, a highly addictive compound found in Vicodin. — location: 2108 ^ref-38559

The laws of our nation and the unique culture of our health care system make the impact of the legacy players far greater in the United States than in the rest of the world. — location: 2118 ^ref-39208

it should be obvious that if our nation seeks to address the economic difficulties that health care spending creates, the legacy players will do their best to stop it. This is the unwritten law of health care economics. — location: 2130 ^ref-35775

For the legacy players, it would have been a disaster. Individuals and companies can decide to make the health care system more efficient, or they can use its existing inefficiencies to drive their profits ever higher. Rarely can they do both. — location: 2137 ^ref-64769

While sailing between England and India, around the southern tip of the African continent, more than 40 percent of every crew would die from the disease. — location: 2143 ^ref-19895

264 years elapsed between a clear medical finding and broad, systemic change. The reason for the delay in progress was the same then as it is today: the power of perception. — location: 2151 ^ref-20519

our resistance to change comes in part from patients and doctors. — location: 2158 ^ref-4680

much of the blame for our current health care problems can be placed squarely on the shoulders of the legacy players. — location: 2159 ^ref-37644

Infants did not survive because of this maneuver or the resulting expansion of their fontanelles. Instead, the babies who lived were the ones suffering the least amount of dehydration. In other words, these children still had enough fluid in their bodies. For them, crying was sufficient to elevate the soft spots. The others were simply too far gone. — location: 2192 ^ref-437

He published his research in the peer-reviewed Medical Journal of Australia in 1985 and expected his findings would rapidly transform medical practice. But for over a decade, doctors continued to blame spicy foods and stress instead of the real cause: infection. — location: 2249 ^ref-38156

It wasn’t until years after his death in an asylum that Semmelweis’s theory started gaining acceptance. French chemist and microbiologist Louis Pasteur, who himself had lost three daughters to infectious disease, was finally able to persuade scientists of the time that the germ theory of disease could be proven through rigorous experimentation. — location: 2265 ^ref-48215

95 percent of the time, the body destroys the less infected “resting cells,” rather than those actively fighting the virus. Researchers don’t know why, exactly, but they were able to show that as the immune system kills these relatively healthy cells, the body releases chemicals that attract more of them to the scene. The more resting cells present, the faster the T-cell count drops. — location: 2275 ^ref-12711

when it comes to the greatest threats facing our health, it just goes to show that much of what we know for sure “just ain’t so.” — location: 2286 ^ref-50638

he took a different path. He began by establishing an innovative fee schedule at his clinic, creating two payment options. Villagers could either pay $50 for a year’s worth of visits or they could volunteer two hours of their time after receiving medical services and recovering from their diseases. — location: 2302 ^ref-47057

David realized that maximizing health takes more than treating people’s acute medical problems. It demands that people recognize and address underlying social and public-health issues, a reality that holds as true in the United States today as it did in the mountains of Mexico back in the 1970s. — location: 2309 ^ref-14664

the zip code in which a person is born, a factor that alone can lengthen or shorten a person’s life by seven years. — location: 2313 ^ref-54804

race or family income, two factors that account for at least 20 percent of a person’s health status. — location: 2314 ^ref-26591

deterioration in health that occurs when communities lack balanced food options, safe places to play, and community programs that encourage healthy behaviors. — location: 2319 ^ref-42638

such social dynamics as education, racial segregation, social support systems, and poverty account for more than one-third of all American deaths in any given year. — location: 2321 ^ref-52688

social settings are two times more likely to determine a person’s risk of premature death than the places in which he or she receives medical care. — location: 2323 ^ref-39117

cigarettes account for 20 percent of all deaths in the United States. — location: 2332 ^ref-33813

if we quizzed a hundred smokers on the dangers and risks involved, ninety or more would get all the answers correct, and yet they still smoke. The reason they do speaks to the powerful relationship between context and perception. — location: 2341 ^ref-58372

only about 14 percent of smokers die from lung cancer caused by cigarettes. As such, smokers see the low overall risk as reassuring. — location: 2348 ^ref-46887

nonsmokers see the dramatically higher relative risk. Smokers, by contrast, focus on the absolute risk. — location: 2349 ^ref-43405

The odds are that the majority of smokers will die from something else. — location: 2350 ^ref-9530

our brains make a point of differentiating direct and indirect causality. — location: 2357 ^ref-606

When doctors fail to screen for colon cancer, statistics tell us that about 26,500 people will die each year (that is, half of all people who die from colon cancer annually). But we can’t be sure who is in which half, so we tolerate the failure. Just as we do with cigarettes. — location: 2361 ^ref-51319

Kill a patient from a dirty colonoscope, and a host of regulators will be in your office the next day. Kill a patient by failing to schedule a colon-cancer screening, and no one gets blamed. One is malpractice. The other is mistreatment. — location: 2363 ^ref-51917

Victims of mistreatment, however, are statistical and faceless. — location: 2366 ^ref-14020

when we’re not yet sick, we fail to take the steps necessary to prevent the problem from happening in the first place. — location: 2370 ^ref-36060

guess what happens when you tell people who are at risk of colon cancer that there’s a safe, painless, once-a-year fecal immunochemical test (or FIT) that (1) can reliably detect cancer, (2) takes only five minutes to complete, (3) can be done in the privacy of their own bathroom, and (4) reduces their odds of dying by 50 percent? — location: 2372 ^ref-14396

value-laden judgments that ignore the influence of a person’s environment. Context is value-neutral. — location: 2387 ^ref-25959

When it comes to the factors that influence our health, context matters immensely. And when we accept that context matters a great deal in shaping our perceptions and decisions, we’re able to identify a wide range of medical problems that are societally based. More important, we can develop new and better ideas for solving them. — location: 2389 ^ref-3338

just fifteen minutes of exercise a day could reduce a person’s mortality risk by 14 percent and increase life expectancy by three years. — location: 2398 ^ref-51141

thirty minutes of exercise five days a week will save the average American $2,500 a year in medical expenses. — location: 2400 ^ref-48079

once again, knowing something and doing something about it are two very different things. — location: 2404 ^ref-48177

Christensen thinks the better solution would be to create financial incentives for employees to exercise, manage their weight, and get the preventive screenings they need. — location: 2417 ^ref-3660

a combination of aggressive and smart regulation can move people and companies in a direction that is best for our nation. — location: 2427 ^ref-31522

Simple, actionable advice is something Chip believes can have a profound impact on American health. — location: 2438 ^ref-7320

David still needed a clear vision and a detailed plan to implement it. — location: 2450 ^ref-2146

David offered free medical care in exchange for two hours of work (financial incentives). He didn’t try to solve all the childhood mortality problems in a single step. Instead, he focused on one opportunity: cleaning up the water (a nudge). And finally, David gave moms with sick infants a set of clear and simple instructions. Boil the water and give babies a large but specific amount every few hours (shrink the change). — location: 2451 ^ref-37387

focusing on bolstering the village’s education. Soon, as the villagers grew more aware of the social and historical context in which they lived, they started questioning the privilege of the wealthy landowners. Why should they have so much when everyone else had so little? A revolt erupted over land reform, and when the authorities heard about it, they came into the town, put down the unrest, and killed many villagers in the process. After that, the health care experiment was drained of its energy. — location: 2456 ^ref-45026

one problem often creates or compounds another. The intersections of stress, anxiety, and physical disease provide a noteworthy example. — location: 2463 ^ref-17252

individuals who make poor health and lifestyle choices experience increased stress that leads to a variety of serious health problems, such as clinical depression, cardiovascular disease, and more frequent colds. It’s a vicious cycle. — location: 2469 ^ref-54788

depression, which alone doubles the risk of cardiovascular disease and more than doubles the risk of a person becoming sick enough to require hospitalization. This compounding effect of the physical and the psychological can send lives spiraling out of control, ruining families and careers. — location: 2477 ^ref-21948

Every year, depression results in 200 million lost workdays, costing employers up to $44 billion. — location: 2479 ^ref-28730

In total, the calculated impact of depression and anxiety disorders on the workplace exceeds the cost of diabetes and heart disease. — location: 2479 ^ref-48359

depression and anxiety disorders are very common and deeply entwined with chronic disease. If either the psychological or the physical issue isn’t recognized and effectively treated, patients are more likely to develop both down the road. — location: 2484 ^ref-23511

In some cases, children suffer publicly recognized tragedies such as the loss of a parent. Too often, however, the source of the problem is a deep, dark secret: the result of growing up in a home with domestic violence, mental illness, or addiction. — location: 2493 ^ref-53867

These physical and emotional traumas damage the lives of children in ways that linger throughout adulthood. — location: 2495 ^ref-52079

we rarely talk about childhood trauma, an even more potent killer. — location: 2497 ^ref-59497

The troubling cause-and-effect relationship between early and later life events is well documented. But as a society, we do little to break this cycle or even openly acknowledge it. Unless physicians explicitly ask about childhood trauma, patients rarely volunteer the information. People who are abused in childhood learn not to trust any authority figure. — location: 2497 ^ref-19787

the CDC has identified adverse childhood experience as one of the nation’s leading causes of poor health. — location: 2503 ^ref-57688

correlation between a traumatic social environment and lifelong health issues is clear. — location: 2506 ^ref-32782

When clinicians treat childhood trauma like any other traumatic injury, they reduce the risk of long-term consequences and lessen the potential for that person to one day harm others through domestic abuse, another sad and silent killer in America. — location: 2510 ^ref-13922

The symptoms of abuse are usually much more subtle: a woman complains to her doctor of depression or insomnia, a coworker stays late in the office every night. Usually, these subtle warning signs of abuse go unnoticed. — location: 2518 ^ref-5809

The expansion of coverage through the Affordable Care Act was designed to close the gap and, to date, the ACA has helped increase coverage for these populations. — location: 2548 ^ref-33742

creative solutions have come from local government and grassroots organizations as well. The city of Baltimore offers one example. — location: 2550 ^ref-21559

On day one in her new role, Dr. Wen recognized that if she wanted to improve the health of the community, she would need to address disparities in health outcomes, particularly when it came to child mortality. — location: 2562 ^ref-20857

Addressing social determinants of health is important to improve the well-being of our nation and extend the life expectancy of our citizens. — location: 2571 ^ref-22488

When a socially determined problem does not affect us or those around us, we’re more likely to blame the individual, fail to factor in the social context, and underestimate the magnitude of its consequences. — location: 2575 ^ref-4883

Like a moth to a flame, American patients are drawn to the health care products and practices that “glitter.” — location: 2581 ^ref-27915

most fail—largely because their approaches follow a faulty and predictable pattern. — location: 2589 ^ref-58663

“unicorns,” start-ups without a track record but with a stock-market valuation of more than $1 billion. — location: 2593 ^ref-48654

Holmes’s idea glittered, a lot, and it helped make her Wall Street royalty, a crown she wore for several years. That was until it was discovered that Theranos’s glitter was nothing more than fool’s gold. — location: 2605 ^ref-58724

In practice, few new medical breakthroughs match their hype. — location: 2613 ^ref-2117

5 percent of patients who account for 50 percent of all health care costs each year. — location: 2618 ^ref-2035

In health care, most ideas and approaches aimed at the 5 percent end up being less effective than their creators hoped or promised. Human biology simply lessens the impact. — location: 2630 ^ref-24059

It was the right decision for her—with an emphasis on “for her.” — location: 2646 ^ref-12608

Only 5 to 10 percent of women with breast cancer have this particular abnormality. That’s why this type of testing fails to provide any actionable information for the overwhelming majority of women and is therefore not routinely recommended by cancer experts. — location: 2647 ^ref-48479

scientists have identified a few genetic markers that could make a difference and not much more. — location: 2658 ^ref-8544

Jolie’s story raises our hopes for genomic testing while underscoring the problem with things that glitter. — location: 2659 ^ref-13936

industry’s projections for applying genomics to human disease and improving health remain heavy in hype and light on proof. — location: 2661 ^ref-44560

regardless of what genomic or genetic testing may indicate, everyone would be better off eating healthier foods, exercising regularly, and getting the appropriate prevention screenings based on their age, sex, and medical history. In spite of our vast and complex genomes, when it comes to our health, most humans have roughly the same basic needs and risks. — location: 2665 ^ref-61722

In the past, consumers have had no easy way of quantifying the differences in clinical outcomes from health plan to health plan, but that too is changing in the era of health care reform. — location: 2674 ^ref-51733

the quality of clinical outcomes you’ll get (and your chances of dying of certain diseases) varies by 20 percent or more. — location: 2677 ^ref-63368

“Many health experts agree that where Oscar excels isn’t in its plan benefit design, but in the way that it markets these offerings to its members.” — location: 2693 ^ref-28777

For all of the enthusiasm and hype these devices drum up, they essentially provide us with data on only two basic functions: sleep and exercise. Most of us already know whether we slept well. And even if the wearable informs us that we tossed and turned last night, what can we do about it? — location: 2712 ^ref-51150

A recent study published in the Journal of the American Medical Association found that people who wore fitness trackers actually had a tougher time losing weight than people who logged their activity on a website. — location: 2718 ^ref-2429

The December Dilemma has been around for quite some time. — location: 2724 ^ref-6628

tech entrepreneurs usually take a backward approach to innovation. They start by discovering a nifty technology. Next, they try to figure out how people can use the product. Finally, they focus on how to monetize it. It’s a recipe for failure. — location: 2745 ^ref-6747

Sometimes, existing tech-enabled solutions can be used in new and innovative ways within a medical setting. — location: 2751 ^ref-4340

physicians in some of Kaiser Permanente’s hospitals started giving their ICU patients an exercise tracker to ensure they got their necessary steps. Although the results are preliminary, more patients are getting up and out of bed. And thanks to the tracker, everyone is aware when they aren’t. — location: 2754 ^ref-6258

tool that could separate the “signal from the noise” for patients, telling them when they’re at risk and when not to worry, would expose device makers to legal action and malpractice suits, should patients suffer a major complication. — location: 2764 ^ref-14033

Until our payment model moves from fee-for-service to “pay-for-value,” some of the most effective technological solutions imaginable will be hard to sell. — location: 2773 ^ref-3731

Ironically, the health care innovations that have achieved both aims are ones few people would label as “breakthroughs.” — location: 2787 ^ref-50935

seat belts save more than 15,000 lives each year in the United States. — location: 2797 ^ref-38486

We see problems that are common as far more dangerous than those we hardly ever encounter. — location: 2837 ^ref-58457

The press can and most likely will continue to ignore it, but 200,000 avoidable deaths each year represents the pinnacle of mistreatment. — location: 2860 ^ref-30063

We can modify the structure, financing, and technology of medical practice in ways that lead to superior medical outcomes for patients and that create a professionally uplifting experience for doctors. — location: 2867 ^ref-21857

Trump’s supporters, many of whom felt left behind by society and government, saw the world very differently than those who voted for Secretary Clinton. — location: 2888 ^ref-42345

“Perceptions are not reality: Things the world gets wrong.” — location: 2907 ^ref-48771

About one-third of the 50 million were relatively poor (but not poor enough to qualify for Medicaid), — location: 2917 ^ref-5024

He needed to make the “unavailable” more readily apparent. So his first step was to help his fellow Americans see the issue. — location: 2929 ^ref-8097

Our context—more than our convictions or values or conscious decisions—determines what we see and how we react to it. — location: 2942 ^ref-44889

once you’ve had to personally go without, you can’t get that experience out of your head. — location: 2946 ^ref-61470

it took me almost no time at all to realize how absurd I must have sounded when counseling my poorer patients on the importance of eating a healthy, balanced diet with fresh fruits and vegetables. — location: 2953 ^ref-14127

At the same time, it represents the most significant change to American health care in over half of a century. — location: 2961 ^ref-41488

to organize the nearly 5,000 residents of Altgeld Gardens Homes and convince them to push city hall for improved living conditions inside their run-down public-housing project. — location: 2964 ^ref-7718

lack of food, education, and medical care in the area precipitated high rates of crime, violence, and death. — location: 2973 ^ref-26230

It was Mayor Washington’s example that helped the future president realize that if he truly wanted to make change happen in Chicago, he would need to earn a law degree. — location: 2978 ^ref-18724

Law was the right choice for his intellect and personality. — location: 2980 ^ref-45560

without his years as a community organizer, he might never have developed the health care “availability bias” he carried into his presidency. — location: 2987 ^ref-48318

President Barack Obama was well informed by studying the efforts, and the failures, of his predecessors. — location: 2991 ^ref-16279

some of those funds went to American medical researcher and virologist Jonas Salk, the man who discovered and later developed the first successful polio vaccine. — location: 3000 ^ref-10268

this unlikely president opted to spend much of his time in office endorsing equal health-insurance coverage for all Americans. — location: 3003 ^ref-21548

President Truman could not overcome repeated attacks from the powerful American Medical Association (AMA), a group that labeled his federal health-insurance bill “socialized medicine.” His plan died in congressional committee. — location: 3005 ^ref-46751

three forces led him to abandon his cause — location: 3015 ^ref-36103

rather than casting a wide net or conducting a rigorous search for a task-force leader, he called upon then first lady Hillary Clinton. A poll at the time reported that 44 percent of Americans thought there were better candidates for the job. — location: 3016 ^ref-8235

Mrs. Clinton relied on a tight inner circle of policy experts for input, in turn alienating a large swath of potential allies. — location: 3017 ^ref-14165

tanking economy of the early 1990s was President Clinton’s second major headwind. — location: 3020 ^ref-18787

Third, as a result of the economic travails, Democrats lost the House during the midterm elections of 1994, a final and fatal dagger that put an end to his health care reform plan. — location: 3021 ^ref-22863

Barack Obama, surveying the massive hill he’d need to climb to effect meaningful change, started his ascent by putting a human face on the imperative to expand health care coverage and restrain its escalating costs. — location: 3038 ^ref-41924

out of a combination of political necessity and personal style, the president embraced a different strategy than his predecessors. Specifically, Obama was cautious from the start. — location: 3048 ^ref-25614

That’s why he announced that the nation’s health care reform plan would be handled openly and transparently from the outset. — location: 3050 ^ref-15274

he took a hands-off approach in the early stages, asking lawmakers to sketch out a first draft, preferring consensus over personal preference. — location: 3055 ^ref-25268

rather than painting the legacy players as villains or obstructionists, the president included them in the discussions, too. — location: 3056 ^ref-23761

Three months before the House passed its version of the law, Senator Ted Kennedy, an avid and career-long proponent of health care reform, died of complications from a malignant brain tumor. — location: 3077 ^ref-45269

accepted that a good law enacted was better than a perfect one killed by partisanship. — location: 3082 ^ref-28551

For this reason, the president, along with Democratic congressional leadership, took the simpler path. Instead of modifying the bill further, they passed the Senate’s version unchanged. — location: 3084 ^ref-946

The passage of the Medicare legislation under the Democrat Lyndon Johnson, a process as contentious as the enactment of the Affordable Care Act, was followed by a rather unexpected twist. Rather than calling for a repeal of Medicare, Richard Nixon, the Republican who succeeded Johnson, called on Congress to expand Medicare to cover people under the age of sixty-five with long-term disabilities. He even added a new health care law of his own: the HMO Act of 1973, which provided millions of dollars in start-up funding for health maintenance organizations (HMOs). — location: 3107 ^ref-8075

“Any program to finance health care for the Nation must take close account of two critical and related problems: cost and quality.” — location: 3111 ^ref-22185

seven years after the signing of America’s most sweeping health care reform, the rate of uninsured had fallen below 9 percent for the first time ever, about half of what it was prior to the ACA’s passage. — location: 3116 ^ref-7280

the economic security of coverage has been psychologically liberating. It has also been valuable in improving their overall health and well-being. — location: 3118 ^ref-7814

Data from states that have maximized ACA coverage and care show large improvements in population health, — location: 3156 ^ref-62973

Beyond its layout and between the lines, you’ll find the unwritten implications of the law and the strategy President Obama thought stood the best chance of addressing the fundamental challenges of American health care today. — location: 3167 ^ref-35735

Left unchecked, at the current rate of inflation, health care costs will ultimately bankrupt the United States. — location: 3172 ^ref-3942

the president sought to address health care’s financial challenges, not by fiat but by altering its rules and norms. — location: 3177 ^ref-56475

rather than trying to reduce their payments on day one, Obama put in place a set of provisions that would influence medical practice over the long haul. — location: 3182 ^ref-34045

His hope was to convince the legacy players that the government’s expansion of coverage would generate enough revenue for them to offset higher taxes or reductions in payment for their services. — location: 3183 ^ref-12202

For those earning a bit more, there were the insurance exchanges, with major subsidies based on income. — location: 3190 ^ref-19917

seven “big bets” on the future of health care: two bets on covering America’s 50 million uninsured and five bets targeting a combination of cost reduction and improved clinical outcomes. — location: 3192 ^ref-27020

About twenty states, most of them Republican-controlled, declined the federal subsidy, refusing to expand their Medicaid programs. As a result, less than half of the targeted 18 million uninsured were enrolled in the program. — location: 3212 ^ref-24059

So it is that politics (more than economics) will determine whether big bet number one ever pays out. — location: 3214 ^ref-34815

For this provision to work, there had to be a catch. So Obama introduced the “individual mandate,” requiring nearly everyone to buy health insurance or pay a penalty. — location: 3230 ^ref-18257

Guaranteeing individual coverage would only work if everyone participated. — location: 3232 ^ref-12447

premium subsidies for individuals based on their annual incomes and tax credits for the smallest businesses. — location: 3244 ^ref-5863

by tying the subsidies to the two lower tiers, Obama hoped to provide incentives for people to take better care of themselves and be more demanding in their choice of providers. — location: 3256 ^ref-5454

Obama chose consumerism. — location: 3263 ^ref-37950

once employers saw people enjoying more choices and competitive prices on the individual exchanges, perhaps they would begin migrating all of their employees to this new model as well. — location: 3266 ^ref-53984

if that happened, competition on the exchanges would intensify, lowering prices even further while boosting quality and accelerating the impact of health care reform. — location: 3267 ^ref-34387

Trump inherited upon his election: (1) about 17 million newly insured Americans, (2) a guaranteed issue law prohibiting insurers from denying those with preexisting conditions, and (3) an established health insurance exchange tool in place. — location: 3271 ^ref-42906

all of the payments were targeted to those programs at or near the top. The president’s big bet was that each year, more enrollees would select the four- and five-star programs. Consequently, the low performers would either have to improve dramatically or exit the market. — location: 3300 ^ref-54306

It took fifteen years after Medicare was passed by Congress for the major kinks to be ironed out. — location: 3302 ^ref-60330

the best place to get the legislative details right would have been in the joint-conference committee. But because that option was null and void after the death of Senator Kennedy, — location: 3339 ^ref-58962

The biggest problem for doctors and hospitals wanting to form an ACO is the transition period. — location: 3353 ^ref-60179

added inefficiency and costs of retaining the extra physicians. — location: 3360 ^ref-7352

Until a truly comprehensive set of medical information is made available to all doctors and hospitals rendering care, these computer systems will continue to increase health care expenses, not diminish them. — location: 3398 ^ref-16313

when drug or device companies want to introduce a new (and often expensive) medication or technology, they must demonstrate that it’s safe and effective. That’s it. They’re not required to prove it’s any better than products that already exist. — location: 3414 ^ref-22009

the pharmaceutical industry enjoys massive profits and minimal interference, thanks to long periods of patent protection for name-brand drugs, the freedom to introduce them without any proof of added efficacy. — location: 3421 ^ref-38052

for the drugs that already exist, monopolistic pricing has become the norm. — location: 3423 ^ref-16882

The ophthalmologists were injecting a very small dose of Avastin in their macular-degeneration patients with excellent clinical results and an average cost per treatment of about $60. — location: 3427 ^ref-24646

instead of seeking FDA approval of Avastin for wet macular degeneration, Genentech created Lucentis, a drug with a biologically active component identical to Avastin. Once Genentech received FDA approval for Lucentis, it priced the drug at $2,300 a dose and tried to prohibit ophthalmologists (or anyone else with a low-cost solution) from obtaining or administering the much cheaper option, Avastin. — location: 3430 ^ref-25375

Increasingly, drug companies are buying the rights to medications that have been in use for decades for the sole purpose of raising their prices, often between 200 and 500 percent, and effectively shutting out the competition. — location: 3438 ^ref-6540

6,000 babies are born with or develop hydrocephalus each year. It affects more than 1 million Americans, from children to adults. — location: 3465 ^ref-46364

hydrocephalus is as common as Down’s syndrome but gets one-thirtieth the public research funding. — location: 3473 ^ref-23885

Parkinson’s disease, which affects a population comparable to that of hydrocephalus, receives $200 million in National Institutes of Health funding, more than triple the amount for hydrocephalus research. — location: 3473 ^ref-17830

In the United States, publicly traded drug and device companies fund almost two-thirds of all medical research. — location: 3476 ^ref-25632

money, volume, and risk. — location: 3478 ^ref-52634

instead of trying to solve difficult clinical issues through major R&D investments, drug and device companies prefer to make a minor modification to an existing drug, patent its successor, and invest most of the dollars in marketing and sales. — location: 3482 ^ref-11825

the online exchanges have given health insurance coverage to 10 million individuals. — location: 3505 ^ref-60228

a combination of general discontent among many citizens and their deep-seated distrust of the traditional political process. — location: 3514 ^ref-753

The gap between perception and the reality of the Affordable Care Act was far wider than I previously imagined. — location: 3518 ^ref-55778

When you insure millions of people with preexisting medical conditions and price their care as if they were of average or even reduced risk, the initial rates would surely be unsustainable. Ultimately, prices had to reflect the cost of providing care to the newly insured. — location: 3524 ^ref-61187

few of the critics acknowledged either the calculus or the consequences of guaranteed issue. — location: 3526 ^ref-33419

opposition to President Obama’s health care reform law was as much about people’s dissatisfaction with their own health care experience—the high costs, inconveniences, and lack of transparency—as it was about the legislation itself. — location: 3527 ^ref-58308

the ongoing and vitriolic dialogue that suffused the first few years of Obamacare implementation served as a metaphor for many of the problems in America, a symbol of the nation’s broad unhappiness with the status quo. — location: 3534 ^ref-55480

we need to be cautious when assuming that short-term happenings portend future events. — location: 3551 ^ref-18837

allowing the federal government to negotiate lower drug prices on behalf of Medicare beneficiaries. — location: 3575 ^ref-23108

through reconciliation, the US Congress can undo several of Obama’s big bets. — location: 3584 ^ref-53558

health-insurance coverage, although essential, is not the fundamental problem facing American medicine. The most important challenge for the nation is health care’s rising cost. — location: 3588 ^ref-27580

“Unsustainable trends can’t continue forever.” — location: 3590 ^ref-44238

Will the Expectations of Patients Change in the Future? — location: 3596 ^ref-40889

Will Care Providers and Insurance Companies Embrace New Reimbursement Models? — location: 3603 ^ref-32902

when it comes to money, what seems fair to one person is perceived as problematic to another, particularly to those who will personally lose income. — location: 3615 ^ref-59913

few use it to enable secure e-mail, video, or direct scheduling of office visits. — location: 3622 ^ref-55089

higher-volume facilities drive better outcomes and that consolidation of smaller hospitals into larger centers-of-excellence improves results. — location: 3627 ^ref-62107

Leadership in health care demands that doctors figure out ways to make innovative and positive things happen that otherwise wouldn’t. — location: 3794 ^ref-45817

That’s why the true test of successful leadership is best measured months or even years later. It is defined by whether those who dragged their feet at first would ever choose to go back to how things were done before. When leaders make the right things happen, the answer is always the same: let’s leave the past in the past. — location: 3798 ^ref-60234

They’re mistreated because the systems and cultures of medicine influence doctors to make decisions that don’t produce the best clinical results. — location: 3807 ^ref-7456

Health care will need to be integrated, — location: 3812 ^ref-20784

Health care will need to be prepaid, — location: 3813 ^ref-14828

Health care will need to be technologically enabled, — location: 3814 ^ref-50234

Health care will need to be physician led, — location: 3816 ^ref-6951

They attract patients with the promise of miracle cures from their research laboratories (even when little of the work itself is medically applicable). — location: 3837 ^ref-13163

By bringing health care into the homes of the community’s “worst of the worst” medical cases, the Camden group cut hospital bills in half. — location: 3877 ^ref-62890

a coalition of doctors working in conjunction with a hospital did. — location: 3879 ^ref-688

what is possible when doctors and hospitals share common systems, incentives, and leadership. — location: 3879 ^ref-5140

Physicians in academia, on the other hand, value their CVs filled with published articles and teaching accolades. But they don’t see the redundancy and inefficiency in their care-delivery systems. — location: 3885 ^ref-36131

They resist change when it competes with other priorities like conducting research and teaching. — location: 3886 ^ref-26713

To increase operational excellence and customer satisfaction in this setting, doctors and researchers will need to be less “ivory tower” and more business savvy. — location: 3886 ^ref-17414

Today, more than 50 percent of medical schools offer a joint degree in business and medicine. — location: 3888 ^ref-6790

Given the chance to go to your local low-volume community hospital or drive an extra twenty minutes to one with twice the volume, always pick the latter. — location: 3931 ^ref-51421

Primary care, through disease prevention and the management of chronic illnesses, can claim credit for 80 percent of the superior clinical outcomes in health care today. — location: 3948 ^ref-3683

When their overall head count increases, primary-care physicians will have the time to become even more adept at helping patients deal with difficult lifestyle issues (smoking, obesity, drug abuse, and so on), and they’ll find better ways to help patients avoid the ravages of chronic illness in the first place. — location: 3956 ^ref-36184

it enables unnecessary “utilization” and even rewards medical errors. It tolerates and perpetuates sky-high prices. In the future of health care, this form of reimbursement simply won’t fly. — location: 3999 ^ref-63758

science informed by technology (not intuition) was guiding conversations with patients. — location: 4022 ^ref-61757

Dr. Carlos Pestana from the University of Texas points out that half of what we know in medicine is wrong. Unfortunately, he reminds us, we just don’t know which half. — location: 4024 ^ref-35808

By 2018, our organization expects to provide our patients with more virtual visits than in-person office visits. We don’t force anyone—doctors or patients—to use this approach. But when it’s offered, nearly every patient chooses it. And when they do, patients report higher satisfaction with virtual care, particularly with video, when compared to in-person visits. — location: 4062 ^ref-48225

State medical boards are another barrier. In Idaho, a doctor was fined $10,000 for prescribing an antibiotic over the phone. — location: 4069 ^ref-46547

physicians are legally prohibited from providing telehealth services “across state lines.” Today, it is legal for a doctor in San Diego to treat a patient in Eureka, California, more than 700 miles away, but not for a physician in, say, Chicago to provide a video visit to a patient thirty miles away in Gary, Indiana. — location: 4070 ^ref-39004

It could start to gain momentum as a low-cost alternative to in-person visits, one that would be especially attractive for people paying their health care expenses out of pocket. — location: 4077 ^ref-54596

Pillar 4: Who Will You Trust? Health care will need to be physician led, which will require greater leadership training and development. — location: 4110 ^ref-8467

As physicians, we often assume we know everything. — location: 4125 ^ref-31681

So physicians who want to lead the future of health care need to be willing to learn. Fortunately, physician leadership is a skill that—as in every industry—can be taught, honed, and developed. — location: 4127 ^ref-35601

no other investment (not in information technology or brick and mortar) has yielded a higher return on investment than our programs to select, train, and develop future leaders. — location: 4143 ^ref-37066

I’ve found that the best of the best, regardless of their industry or the challenges they face, demonstrate the ability to touch and influence three vital organs of their fellow colleagues: the heart, brain, and guts. — location: 4147 ^ref-2342

The bigger the heart, the greater the impact. — location: 4161 ^ref-54586

Successful leaders distribute data to show variations in results and what the highest performing physicians are able to accomplish. Often, the first step in the change process is to help everyone recognize that what seems impossible, isn’t. After all, someone is likely already achieving the desired outcome. — location: 4169 ^ref-4993

Leaders can’t be foolhardy. But those without the bravery needed to address performance issues or make a clear decision despite certain risk will not just underperform themselves, they’ll lose the confidence and trust of those around them. — location: 4185 ^ref-13483

They need to provide an aspirational vision, detail the behaviors expected, present context and data, and engage in authentic ways with the people they hope will follow them. — location: 4189 ^ref-54633

sincerity and skill, — location: 4190 ^ref-29343

Dr. Devi Shetty — location: 4192 ^ref-44690

“charity is not scalable,” — location: 4201 ^ref-38125

He understands that “operational excellence” requires a razor-sharp focus on every detail. — location: 4203 ^ref-15220

Thirty percent of medical students and residents are depressed, and over half of doctors feel burned out. — location: 4301 ^ref-13055

At most jobs, failure to communicate is a daily occurrence with minor or moderate consequences. — location: 4409 ^ref-40571

In the brightly lit room, students reported getting fewer than eight answers right on average, whereas those in the dimly lit room reported getting almost twelve answers correct on average. Simply darkening the room increased cheating by 50 percent. — location: 4432 ^ref-43709

Those with sunglasses (who felt more anonymous) gave an average of $1.81, keeping $4.19. — location: 4439 ^ref-40710

When individuals wear sunglasses or find themselves in a dark room, they feel more anonymous and their behaviors change. — location: 4441 ^ref-61646

in the context of working among associates who did the same thing, the surgeons’ perception shifted. Maybe if they had to fill the forms out themselves, they would have completed them correctly. Maybe if they had different senior partners, they would have been more honest. But once perception shifts, so does behavior. — location: 4453 ^ref-40790

There is not the same perception of loss among credit-card users. — location: 4467 ^ref-32775

than — location: 4492 ^ref-15532

So I told him about my confidence in the ACA and how much I enjoyed the experience. When our benefits kicked in, the savings were almost enough to offset my daughter’s first year in college. For me, that was a big deal.” — location: 4567 ^ref-31299

the current approach to health coverage separates the expense of providing care from the cost of buying insurance. — location: 4609 ^ref-18891

until doctors embrace the changes necessary to improve quality outcomes and drive down the costs of care. — location: 4611 ^ref-26740

“You stopped asking me how I was doing and what I was feeling,” she said. “I didn’t know any other way to get your attention.” — location: 4641 ^ref-31108

I always asked each patient before I left the room, whether in the hospital or the office, if there was anything else that patient wanted to tell me. — location: 4643 ^ref-28405

“no one cares how much you know, until they know how much you care.” — location: 4647 ^ref-35822

I wanted to continue to live for my family and for myself, because I love life and I still have a lot to teach these kids.” — location: 4665 ^ref-58753

multispecialty medical group, — location: 4669 ^ref-42860

comprehensive electronic medical-record system, — location: 4679 ^ref-25182

“Life ends and we should enjoy each day.” — location: 4727 ^ref-40696

“You will never be a good farmer, but if you work hard at it, you might become a great physician.” — location: 4728 ^ref-63284

when there is nothing more we can do for our patients by way of medical treatment, the most important skill we possess is our ability to show compassion, especially at the end of a patient’s life. — location: 4730 ^ref-57767

I would give patients my home phone number after outpatient surgery. — location: 4735 ^ref-10960

It’s remarkable to me how often doctors try to protect themselves from the 1 percent of patients who will abuse a privilege. Little do they realize that in doing so, they project their distrust onto the other 99 percent, — location: 4739 ^ref-8322

Change always feels uncomfortable at first. That is its nature. — location: 4771 ^ref-30835

amid rapid change, it’s tempting to feel like a victim and cling to the past. It feels safer. But embracing the future usually proves most rewarding. — location: 4771 ^ref-26878

Achieving delivery-system improvement is the fundamental challenge our nation faces. — location: 4789 ^ref-51256

Every year, my brother, Ron, and sister, Karen, take time to connect on the anniversaries of our parents’ deaths. Doing so reminds me how grateful I am for the love and emotional support of my siblings. — location: 4841 ^ref-21535