Health Risk and Pleasure

I thought I would post this one from The Physician Executive because Val was once my favorite internet buddy. My Canadian ex-compatriate is now remarried and has moved to South Carolina. But one thing has not changed: the timeless notion that people somehow view healthcare as a way to dodge the consequences of overindulging their little pleasures. In this case we are talking about something relatively innocent: unpasteurized dairy consumption. Our health officer in Clark County gets upset every time he hears about another place selling raw milk in Clark County. The latest I found was Camas Produce selling raw goat’s milk.

It’s easy to condemn the practice of consuming raw dairy on its scientific basis. Trouble is I love artisanal French cheeses. Many are raw and were outlawed int he US at the time this post was written in 2007. I am a happy camper now that I can get unpasteurized cheese. I hope Dr. Melnick will forgive me this one indulgence.


Dr. Val at the Voice of Reason posted an article on the hazards of raw milk. She grew up on a dairy farm, so her observations are particularly cogent. The article raised two questions in my mind.

First, our clinic’s practice is heavily Latino, dominated by Salvadoreans who have a tradition of consuming raw milk products. In fact, Salvadoreans consider yogurt made from raw milk one of the healthiest foods for young infants. My patients tell me it is usually introduced at around two or three months of age.

Of course, this goes against the usual recommendations for baby feeding in the US, which appears to me to be based on bowel maturity and propensity for allergies, as much as on healthy nutrition. There have been sporadic cases of bovine mycobacteria amongst Hispanic infants in our area, which is a stone’s throw and a ferry ride across the Potomac from Dr. Val’s stomping grounds (so much for anonymous blogs, eh?)

My classic and rigorous medical training causes me to carefully counsel my patients against the consumption of anything other than breast milk and formula for the first four months and to avoid raw milk products until they are old enough to choose for themselves. My cultural sensitivity makes me wonder if this is truly appropriate.

Yogurt, perhaps reserved for later infancy, is probably a great source of nutrition to have become an important staple in El Salvador. Culture is important to everyone who has one, and food and child-rearing are important aspects of culture. The documented number of infections in our County was 4 in 2005. Is that enough to intrude on culture and tradition, or can we just remain sensitive to the fact that these children are at risk an intervene early? I’ve never had to treat an infant with cow tuberculosis in their gut, but I wonder… I just wonder…

The second thought that came to my mind is about the French! No I’m not getting political… I just like French cheese. One of my favorites is Camembert from Normandy made from raw milk. Perhaps there is something in the process of making cheese that I am missing, but raw milk cheeses taste better and have been really hard to find because of the Department of Agriculture’s import restrictions. I just found a really smelly cheese store nearby and I’m in heaven. The first thing I asked is if they had raw cow’s milk cheese and the guy behind the counter smiled and nodded knowingly. He probably figures me for a connoisseur for asking!

Raw milk products have inherent hazards, but this isn’t like eating a puffer fish prepared by a novice sushi chef.

Just wondering…

Disruptive Innovation

This is based on an old post from The Physician Executive when I first started thinking about the place of disruptive innovation in health care delivery.


The problem with disruptive innovation in health care is thinking twice about how it applies.

A couple of precepts before we begin, just so we’re all on the same page, or at least the same library:
1) First the technology can exist for a long time before it is adopted, if at all. It is in the application that an innovation potentially becomes disruptive.
2) Adoption is likely to come from smaller players as new technologies are frequently overlooked by the big players.
3) The innovation is not disruptive to the consumer. It is disruptive to other producers. The consumer adopts it because it is simpler and cheaper than the alternative.

In my world, the innovation will come from changes in the way health care is delivered, not about a sexy new scanner or robotic procedure or even a new iPad app for diabetics. And here, observations about how slowly such innovations are taken up become pertinent.

I would argue against big business. Lately, consolidation has caused health care to be delivered out of monolithic medical systems incorporating primary care, specialty, allied health (physical therapy, audiology, optometry among others) and imaging services. This creates a few problems:

1. Like big government, big business generates an entrenched bureaucracy that is resistant to change, difficult to navigate and primarily interested in perpetuating itself.

2. Incentives are skewed to generate more testing and services. Primary care, when properly delivered, reduces downstream costs to the system, meaning less revenue for the organization.

3. There is less choice (see availability of reproductive services in areas dominated by large Catholic health systems) and the cost advantages of scale initially required to reap the benefits of the technology deployed are rarely manifest.

Carving primary care out of the health care delivery system and providing a special place for it with better revenue, greater legal protection (e.g. tort reform, voiding non-competes) and subsidizing an infrastructure to allow small, personal, relationship-based practices would be a tectonic shift on how we think about health care.  Now that would be disruptive; and just as the iPhone disrupted the PC market, it is only primary care that can disrupt the medical tech (specialty/referral/imaging) sector.

Maybe this is why Clayton Christensen believes health care is ripe for disruptive innovation, although the comments confirm to me that he has not yet found the right disruptions. It will be up to people like Dave Chase, Rob Lamberts and Brian Forrest to figure it out. I could include others, but why take sides?

What the Heck is Cultural Competence?

I stumbled across this old post about Washington trying to pass a bill mandating continuing education for physicians on cultural competence. They just did it again in the legislative session that ended. Again the bill died, but not the one mandating education on suicide prevention.

Suicide prevention is a wonderful thing, but I will be obligated to spend six hours of my valuable time learning about something I bet I do better than 99% of the doctors in this state. I’m not being cocky, it’s just that we have very few psychiatrists around and I have had to upgrade my psychiatric, pharmacology and counselling skills.

The sad part is that it will not help suicide prevention because CME is superbly badly suited to the skill required. So here is the old post.


Washington State has chosen to address the cultural competency of their physicians and providers.

While this is laudable in purpose, an effort to assure cultural competence is difficult to implement well. On the face of it, additional training seems the logical response to a deficit in cultural competence. Unfortunately, continuing medical education and training has never been demonstrated to effectively change the practice patterns of physicians, so there is no reason to believe it will work here.

One could try to increase the diversity of the physician supply, but my experience is that whereas this may improve the satisfaction of people with similar ethnic and cultural backgrounds, it does not address the competence of physicians dealing with a diverse group of patients. Foreigners of any given ethnicity are no better able to deal with other ethnicities than a plain vanilla white American boy.

Moreover, the way cultural competence is presented can be dangerous, the way many well-intentioned efforts succumb to the law of unintended consequences. For example I recently received a brochure from The Joint Commission (aka JCAHO) which represents different ethnic groups and their usual beliefs and behaviors about illness.

Many of the ‘facts’ presented are truisms and platitudes that only hold for some people in any given population. Not every Hmong rubs coins on their childrens’ backs and not every Latina mother thinks about cold and hot illnesses. These beliefs are typical of ordinary people and thus much more dramatically influenced by socio-economic status within the culture that by the culture itself. It is tantamount to calling an Asian smart or an African athletic. Whether or not the statement hold true in the aggregate, the seed of prejudice (i.e. pre-judging) lies in assuming that the person in front of you shares those attributes.

Perhaps there is a different way to assure cultural competence, but also to address the underlying issues for poor communication between physicians and patients. Physicians are taught interpersonal and communication skills in medical school and residency, but the training is uneven and inconsistent between programs. To deal with every person on a psychosocial continuum is to see them as a unique collection of ethnic, cultural, social, family personal, biological and genetically determined experiences that need to be peeled away layer by layer without assumption, judgment or bias. Culture rightly become a focus, but only of one of several factors which shape the interaction.

In the cognitive specialties, like the primary care specialties, the ability to provide satisfactory care without excessive investigation is the key to assuring low-cost, high-quality health outcomes.

I would propose we completely and utterly abandon cultural competence (by the way, I am convinced Washington State is using “competency” in a grammatically incorrect way) as the framework for how we approach patients and replace with a broader psychosocially defined “communication competence concept.” These can be taught through the current channels with an IOM-driven effort to influence curricula via ACGME and the AAMC. In other words, use current channels to support a broad communication-skills agenda rather than a narrow-focus of cultural competence.

Some resources can be found at HRSA, Joint Commission (aka JCAHO) and the ANM.

Immigration and Health Care Costs

Impressions from a cross-country road trip dominates this
Physician Executive post from 2008. The cultural diversity of the country made a big impression on me. It is ironic that while we argue today about Immigration Reform, the pressure from immigration has been dissipated by new economic realities. Net migration from Mexico is now negative. I suspect it is only a matter of time before xenophobia rears its ugly head again in the healthcare debates.


In my drive across the country, I encountered many languages. Coming from a polyglot city like DC, it is easy to be jaded about the American heartland and consider fairly white-bread. This is why it struck me that I encountered so many cultures along the way. I could have said that there were more non-English culture Americans along the way, but then I would be grandstanding.

I did run into a family of Greeks from Turkey along the way, an almost vanished cultural subgroup. Mostly I found myself conversing in my broken Spanish. First was a family from Cuba and we met in the St. Louis arch. Of course the dominant group was Mexican-American, who manned convenience stores, restaurants and hotels the entire length of the country, even in the most white bread areas. I even saw a young black man cleaning a hotel room, a truly unaccustomed site in this country over the last decade, but it was at a National Park, where reasonably affluent young adults work hard in exchange for the adventure of their lives.

All these impressions came on the heels of a radio talking-head saying something to the effect that the trouble with this country was the extent of illegal immigration. He was saying that people seemed to think it was OK to break the law or to simply ignore it in such unprecedented numbers.

So, that would mean that all laws must be vigorously enforced at all times. I’m glad this guy isn’t in charge of the highway administration; I would have been in trouble with speeding especially in some abandoned stretches of road in the West. But the level of policing required to eliminate all speeding in the country would be onerous, certainly it would be cost-prohibitive. Before the ACLU lost its way when the real issues gradually disappeared, they would have gently reminded us that not all laws are meant to be enforced severely given the risk that we could begin to look like a police state; a deplorable condition to be avoided at all costs. Indeed the fathers of this country did proclaim their liberty, or their lives!

If a law requires such severe and absurd efforts like building a wall across a natural resource like the Rio Grande, then I would consider the law worthy of re-evaluation. A law of the land is not a natural law. It is not the Law of Evolution, it is not a Law of God handed down to Moses, or elucidated by Mohammed or revealed by Christ. This country’s laws reflect intelligent people’s best bet on how to secure the greater good.

Our immigration laws are not only ineffectual; they are economically and socially counter-productive.

I caught a CSPAN rerun of Chris Matthews plugging his new book and he suggested that he had a problem with providing government documents to people who were not supposed to be here, i.e. making someone look like they had a status or legitimacy they did not have. That, I can understand. His position reflects serious thinking about how to approach the problem of rapid, undocumented immigration. But stopping immigration altogether is a boneheaded concept. Stopping illegal immigration is unlikely, given the strength of the forces behind migration. In fact, it is the complexity of human migration decisions that makes draconian immigration enforcement so stupid.

It is also economically counter-productive since I am convinced that labor is an asset for any country and does not represent a net burden in services. Some services relate to infrastructure that already exists and incremental increases are not necessarily harmful. Other services such as health care have raised some people’s hackles.

Those people who are up in arms over health care costs to immigrants need to come off it! Immigrants, especially illegals are mostly young, fit and hard-working. They do not come with the express purpose of seeking free health care for themselves or their families, although that may play into their needs after several years if their parents fall ill. There are numerous indications that immigrants, and especially illegals, use less health care and are more likely to pay for it than America’s own native poor. (By native, I mean born in the USA.)

The major burden in most areas is a fertility rate that approaches third world levels, but we’re too busy preaching the ineffectual dogma of abstinence to do anything about it (but that’s another post.) If anyone bothered to do a detailed economic accounting of the costs and benefits, I suspect it would quickly become clear that even illegal immigration is of net economic benefit to this country. Issues related to national security are just more fear-mongering to which I have become inured.

In construction and agriculture alone, this work force represents the ultimate in flexible, mobile work force to do labor of a kind no American would accept to do for any wage. To get native born-American to take up the back-breaking toil which is manual farm labor, we would all be looking at $8 tomatoes and a $20 head of cabbage.

If the problem is that there are too many immigrants, then I say it is the same old xenophobia that has affected people since time immemorial; a mean-spirited, deeply-rooted human fear of all that is unfamiliar. If the problem is only that such immigration is illegal, then I say change the laws. They are too impractical and poorly thought out for my liking. There are better and more intelligent ways to deal with a big incentive for economic migration from our southern neighbors.

The fear of health care costs related to immigration is just one more ideological bone from the political demagogues.