Saving Lives by Stripping the Power of Doctors
Clayton M. Christensen is a professor of business administration at the Harvard Business School. He is the bestselling author of five books, including his seminal work, The Innovator's Dilemma, which received the Global Business Book Award for the best business book of the year, and most recently, The Innovator's Prescription, which examines how to fix our healthcare system. Christensen serves on several public and privately traded boards and is the founder of a successful consulting company and an investment management firm. He holds a B.A. with highest honors in economics from Brigham Young University and an M.Phil. in applied econometrics and the economics of less-developed countries from Oxford University, where he studied as a Rhodes Scholar; he received an MBA with high distinction from the Harvard Business School in 1979, graduating as a George F. Baker Scholar, and was awarded his DBA from the Harvard Business School in 1992.
Topic: Bringing Disruptive Innovation to Healthcare
Christensen: A good way to visualize how disruptive innovations transform an industry is if you think of the geography of an industry as a set of concentric circles.
I’m Clayton Christensen, the Robert and Jane Cizik Professor of Business Administration at the Harvard Business School.
Question: How can disruptive innovation transform healthcare?
Christensen: The advent of sophisticated healthcare technology in the form of surgical suites and advanced imaging equipment and these big high speed multi-channel blood testing and analytical equipment has driven a centralization of the healthcare industry, so we have to take the patients to the hospital rather than to bring the solution to the problem. Now, do you think hospitals will ever become cheap by competing against each other? No. They’ll actually become more expensive. So what we need to do is drive the disruptive decentralization of the healthcare industry and we do that by bringing technology to outpatient clinics, so you can begin doing there the simplest of the things that within the past required a hospital and then keep driving that technology so that they can do more and more and more sophisticated things in that setting. And then we bring technology to doctor’s offices so they can begin doing the simplest of the things that previously had to be referred to a more expensive clinic and then drive that technology so that you can do in the doctors' office more and more the things that were required at the higher cost clinic. And then use technology to drive care to the home. And in a similar way, do you think healthcare will become cost effective if we just expect doctors to take pay cuts? That will never happen but instead we need to bring technology to physicians assistants and nurse practitioners so that they can begin doing the simplest of things that previously required a doctor and then drive that technology so that they can do more and more of those things. In other words, it’s by enabling lower cost venues of care and lower cost caregivers to become more and more capable of doing more remarkable things. That’s the mechanism by which healthcare becomes affordable not by expecting the expensive ones to become cheap.
Question: What specific innovations are most vital to the future of healthcare?
Christensen: Personal electronic medical records are very important to the future of healthcare. The challenge that we have to confront is care has to be coordinated and the reason why care has to be coordinated is there are interactions amongst drugs which if one provider prescribes a patient to take one set of drugs and another provider prescribes a different set for different disorders, those two things might interact in the patient’s body in really adverse ways and create real problems. One provider needs to know what other providers have previously done, so that we know whether or not a patient responded to a therapy so that we don’t duplicate tests and so on. Electronic medical records are really very important to assure that the right care is delivered to the right people without duplication or contradiction. In the past, a doctor could provide all of that coordination. The problem is there are so many more drugs now and so much more is known about how these drugs interact with each other and the system is fragmented enough that coordinating a patient’s care is actually beyond the cognitive ability of the world’s smartest doctors. They simply cannot keep in their mind a coordinated picture of all of the possible interactions and all of the possible sequences of care that all of their patients are experiencing. The only way to do it is to have the coordination be done by an information technology system where information about these issues is brought together and algorithms exist that will flag for the doctor and for the patient where there are problems or where there are experiences in the past from which we can learn. So these records are really very important. I think the perception in Washington of the state of digital medical records is very skewed. What they see is the patient with the doctor in the doctor’s office and the doctor continuing to write prescriptions on paper and keep the records on paper but that’s kind of the equivalent in telecom of the last 50 feet of the last mile and that indeed hasn’t been well-digitized, but 97% of all transactions and activities in the healthcare systems already are digitized and so the drug companies, the pharmacies, pharmacy benefit managers, insurance companies, everything they do is digitized. The major healthcare systems like Kaiser Permanente or Intermountain Health, Geisinger or here in the Boston area Partners, their activities are all digitized. So 97% of the data is already there. The problem is that as a natural first step in creating these electronic systems, the systems are not yet compatible. So each company has its own system and that’s a very natural first step. Now, we need technology that virtualizes the interface that enables the systems to talk to each other. That’s the problem and it will just take a little bit of time but it’s been solved in many other contexts. So it used to be that financial records were kept by different companies in different formats but they were able to ultimately virtualize those records so that all of us have a single place we can go to get our credit score even though the inputs come from many different people. This will happen.
Question: Are any low-cost technologies transforming the industry?
Christensen: There are a lot of wonderful devices that are simple and affordable that is driving the decentralization of healthcare. One set of devices have come a Seattle based company called SonoSite and from GE Medical Systems and this a little handheld ultrasound, a piece of ultrasound equipment. Now, if you ask the radiologist who has a very expensive Philips cart-based ultrasound system, these little handheld devices are just really crummy, don’t have anywhere near the functionality that the big system has. But if instead you bring that handheld system to the primary care physician or a nurse practitioner who is doing your annual physical exam, you know, in the past, the only way they could sense what was going on in the body was to feel for it or to listen for it with the test stethoscope and you give this people this little handheld ultrasound equipment, and my goodness, now they can look inside your body and do so much better a job at identifying nasant problems that might be emerging. And so at the periphery, at the distributed end of this disruptive decentralization, we’re bringing much greater capability to be more precise in the practice of medicine. The very same technology tried to deliver in the middle of the circle actually compromises quality. So that’s just one example. Let’s see…. other examples are the ability to determine whether you're pregnant or not, the ability to measure how quickly your blood clots. Point of care diagnostics are distributing the ability to figure out what’s gone wrong too a much larger population of people who can then act on that without the advise or direction of the experts in the middle.
Business strategist Clayton Christensen argues that nurse practitioners and retail health outlets should have increased authority in treating patients.
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The COVID-19 pandemic is making health disparities in the United States crystal clear. It is a clarion call for health care systems to double their efforts in vulnerable communities.
- The COVID-19 pandemic has exacerbated America's health disparities, widening the divide between the haves and have nots.
- Studies show disparities in wealth, race, and online access have disproportionately harmed underserved U.S. communities during the pandemic.
- To begin curing this social aliment, health systems like Northwell Health are establishing relationships of trust in these communities so that the post-COVID world looks different than the pre-COVID one.
COVID-19 deepens U.S. health disparities<p>Communities on the pernicious side of America's health disparities have their unique histories, environments, and social structures. They are spread across the United States, but they all have one thing in common.</p><p>"There is one common divide in American communities, and that is poverty," said <a href="https://www.northwell.edu/about/leadership/debbie-salas-lopez" target="_blank">Debbie Salas-Lopez, MD, MPH</a>, senior vice president of community and population health at Northwell Health. "That is the undercurrent that manifests poor health, poor health outcomes, or poor health prognoses for future wellbeing."</p><p>Social determinants have far-reaching effects on health, and poor communities have unfavorable social determinants. To pick one of many examples, <a href="https://www.npr.org/2020/09/27/913612554/a-crisis-within-a-crisis-food-insecurity-and-covid-19" target="_blank" rel="noopener noreferrer">food insecurity</a> reduces access to quality food, leading to poor health and communal endemics of chronic medical conditions. The U.S. Centers for Disease Control and Prevention has identified some of these conditions, such as obesity and Type 2 diabetes, as increasing the risk of developing a severe case of coronavirus.</p><p>The pandemic didn't create poverty or food insecurity, but it exacerbated both, and the results have been catastrophic. A study published this summer in the <em><a href="https://link.springer.com/article/10.1007/s11606-020-05971-3" target="_blank">Journal of General Internal Medicine</a></em> suggested that "social factors such as income inequality may explain why some parts of the USA are hit harder by the COVID-19 pandemic than others."</p><p>That's not to say better-off families in the U.S. weren't harmed. A <a href="https://voxeu.org/article/poverty-inequality-and-covid-19-us" target="_blank" rel="noopener noreferrer">paper from the Centre for Economic Policy Research</a> noted that families in counties with a higher median income experienced adjustment costs associated with the pandemic—for example, lowering income-earning interactions to align with social distancing policies. However, the paper found that the costs of social distancing were much greater for poorer families, who cannot easily alter their living circumstances, which often include more individuals living in one home and a reliance on mass transit to reach work and grocery stores. They are also disproportionately represented in essential jobs, such as retail, transportation, and health care, where maintaining physical distance can be all but impossible.</p><p>The paper also cited a positive correlation between higher income inequality and higher rates of coronavirus infection. "Our interpretation is that poorer people are less able to protect themselves, which leads them to different choices—they face a steeper trade-off between their health and their economic welfare in the context of the threats posed by COVID-19," the authors wrote.</p><p>"There are so many pandemics that this pandemic has exacerbated," Dr. Salas-Lopez noted.</p><p>One example is the health-wealth gap. The mental stressors of maintaining a low socioeconomic status, especially in the face of extreme affluence, can have a physically degrading impact on health. <a href="https://www.scientificamerican.com/index.cfm/_api/render/file/?method=inline&fileID=123ECD96-EF81-46F6-983D2AE9A45FA354" target="_blank" rel="noopener noreferrer">Writing on this gap</a>, Robert Sapolsky, professor of biology and neurology at Stanford University, notes that socioeconomic stressors can increase blood pressure, reduce insulin response, increase chronic inflammation, and impair the prefrontal cortex and other brain functions through anxiety, depression, and cognitive load. </p><p>"Thus, from the macro level of entire body systems to the micro level of individual chromosomes, poverty finds a way to produce wear and tear," Sapolsky writes. "It is outrageous that if children are born into the wrong family, they will be predisposed toward poor health by the time they start to learn the alphabet."</p>Research on the economic and mental health fallout of COVID-19 is showing two things: That unemployment is hitting <a href="https://www.pewsocialtrends.org/2020/09/24/economic-fallout-from-covid-19-continues-to-hit-lower-income-americans-the-hardest/" target="_blank" rel="noopener noreferrer">low-income and young Americans</a> most during the pandemic, potentially widening the health-wealth gap further; and that the pandemic not only exacerbates mental health stressors, but is doing so at clinically relevant levels. As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413844/" target="_blank" rel="noopener noreferrer">the authors of one review</a> wrote, the pandemic's effects on mental health is itself an international public health priority.
Working to close the health gap<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDc5MDk1MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTYyMzQzMn0.KSFpXH7yHYrfVPtfgcxZqAHHYzCnC2bFxwSrJqBbH4I/img.jpg?width=980" id="b40e2" class="rm-shortcode" data-rm-shortcode-id="1b9035370ab7b02a0dc00758e494412b" data-rm-shortcode-name="rebelmouse-image" />
Northwell Health coronavirus testing center at Greater Springfield Community Church.
Credit: Northwell Health<p>Novel coronavirus may spread and infect indiscriminately, but pre-existing conditions, environmental stressors, and a lack of access to care and resources increase the risk of infection. These social determinants make the pandemic more dangerous, and erode communities' and families' abilities to heal from health crises that pre-date the pandemic.</p><p>How do we eliminate these divides? Dr. Salas-Lopez says the first step is recognition. "We have to open our eyes to see the suffering around us," she said. "Northwell has not shied away from that."</p><p>"We are steadfast in improving health outcomes for our vulnerable and underrepresented communities that have suffered because of the prevalence of chronic disease, a problem that led to the disproportionately higher death rate among African-Americans and Latinos during the COVID-19 pandemic," said Michael Dowling, Northwell's president and CEO. "We are committed to using every tool at our disposal—as a provider of health care, employer, purchaser and investor—to combat disparities and ensure the <a href="https://www.northwell.edu/education-and-resources/community-engagement/center-for-equity-of-care" target="_blank" rel="noopener noreferrer">equity of care</a> that everyone deserves." </p><p>With the need recognized, Dr. Salas-Lopez calls for health care systems to travel upstream and be proactive in those hard-hit communities. This requires health care systems to play a strong role, but not a unilateral one. They must build <a href="https://www.northwell.edu/news/insights/faith-based-leaders-are-the-key-to-improving-community-health" target="_blank" rel="noopener noreferrer">partnerships with leaders in those communities</a> and utilize those to ensure relationships last beyond the current crisis. </p><p>"We must meet with community leaders and talk to them to get their perspective on what they believe the community needs are and should be for the future. Together, we can co-create a plan to measurably improve [community] health and also to be ready for whatever comes next," she said.</p><p>Northwell has built relationships with local faith-based and community organizations in underserved communities of color. Those partnerships enabled Northwell to test more than 65,000 people across the metro New York region. The health system also offered education on coronavirus and precautions to curb its spread.</p><p>These initiatives began the process of building trust—trust that Northwell has counted on to return to these communities to administer flu vaccines to prepare for what experts fear may be a difficult flu season.</p><p>While Northwell has begun building bridges across the divides of the New York area, much will still need to be done to cure U.S. health care overall. There is hope that the COVID pandemic will awaken us to the deep disparities in the US.</p><p>"COVID has changed our world. We have to seize this opportunity, this pandemic, this crisis to do better," Dr. Salas-Lopez said. "Provide better care. Provide better health. Be better partners. Be better community citizens. And treat each other with respect and dignity.</p><p>"We need to find ways to unify this country because we're all human beings. We're all created equal, and we believe that health is one of those important rights."</p>
Can passenger airships make a triumphantly 'green' comeback?
Large airships were too sensitive to wind gusts and too sluggish to win against aeroplanes. But today, they have a chance to make a spectacular return.
Vegans and vegetarians often have nutrient deficiencies and lower BMI, which can increase the risk of fractures.
- The study found that vegans were 43% more likely to suffer fractures than meat eaters.
- Similar results were observed for vegetarians and fish eaters, though to a lesser extent.
- It's possible to be healthy on a vegan diet, though it takes some strategic planning to compensate for the nutrients that a plant-based diet can't easily provide.
Comparison of fracture cases by diet group
Credit: Tong et al.<p>The results showed that vegans were especially vulnerable to hip fractures, suffering 2.3 times more cases than meat-eaters. Vegetarians and pescatarians were also more likely to suffer hip fractures, though to a lesser extent.</p><p>One explanation may be that non-meat eaters consume less calcium and protein. Calcium helps the body build strong bones, particularly before age 30, after which the body begins to lose bone mineral density (though consuming enough calcium through diet or supplement can <a href="https://ods.od.nih.gov/factsheets/Calcium-Consumer/" target="_blank">help offset losses</a>). Lower bone mineral density means higher risk of fracture.</p><p>Protein seems to help the body absorb calcium, <a href="https://www.bonejoint.net/blog/did-you-know-that-certain-foods-block-calcium-absorption/#:~:text=Historically%2C%20nutritionists%20have%20warned%20that,may%20increase%20intestinal%20calcium%20absorption." target="_blank" rel="noopener noreferrer">when consumed in normal levels</a>. The recent study, along with past research, shows that people who don't eat meat tend to have lower levels of both protein and calcium. When the researchers accounted for non-meat eaters who supplemented their diets with calcium and protein, fracture risk decreased, but still remained significant.</p>
Credit: Pixabay<p>Another explanation is body mass index (BMI). Non-meat eaters tend to have a lower BMI, which is associated with higher fracture risk, particularly hip fractures. In the new study, vegans with a low BMI were especially likely to suffer hip fractures. That might be because having more body mass provides a cushioning effect when people fall.</p><p>Still, the study has some limitations. For one, White European women were overrepresented in the sample. The researchers also didn't collect precise data on the type of calcium or protein supplementation, diet quality or causes of fractures.</p><p>Another complicating factor: Producers of vegan products, such as plant-based milk, are increasingly fortifying foods with nutrients like calcium and protein, so modern vegans are potentially at lower risk of deficiency.</p><p>The researchers wrote that their findings "suggest that bone health in vegans requires further research."</p>
Staying healthy on a vegan diet<p>So, does a vegan diet necessarily lead to worse bone health? Not necessarily. But it's safe to say that people who don't consume meat, dairy and eggs should be extra vigilant about consuming enough essential nutrients. That can be harder than it seems.<br></p><p>One major reason is that the body generally has an easier time absorbing nutrients from animal foods than plant-based products. So, while a salad could contain the same amount of calcium as a glass of milk, the body absorbs more calcium when you drink milk. What's more, there are some molecules and <a href="https://www.healthline.com/nutrition/7-nutrients-you-cant-get-from-plants#5.-Docosahexaenoic-acid-(DHA)" target="_blank">nutrients you simply can't get from plants</a>.</p><p>As such, many vegans round out their diets with supplements, including zinc, iron, iodine, long-chain omega-3s, and vitamins D, K-2, and B-12, to name a few. If you're on a vegan diet or considering making the switch, it's probably best to consult a dietician, and to make sure you maintain a <a href="https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html" target="_blank" rel="noopener noreferrer">healthy BMI</a>.</p>
A study by UK archaeologists finds that longbows caused horrific injuries similar to modern gunshot wounds.
- UK archaeologists discover medieval longbows caused injuries similar to modern gunshot wounds.
- The damage was caused by the arrows spinning clockwise.
- No longbows from medieval times survived until our times.
Battle of Agincourt.
The angle of entry into a cranium found during the excavation at a medieval Dominican friary in Exeter, England.
Credit: Oliver Creighton/University of Exeter
Never made a turkey before? Don't worry, science can help.
- This year, many people will be making a Thanksgiving dinner for the first time. It's often harder than it looks.
- Luckily, an online calculator website has one just for thawing turkey, and can explain why you need to wait so long.
- The website has other calculators as well, for needs you didn't know you had.
How to thaw a turkey using science!<p> The Omni Calculator <a href="https://www.omnicalculator.com/" target="_blank" rel="noopener noreferrer">website</a> is home to calculators that can determine many things, including how <a href="https://www.omnicalculator.com/other/sunscreen" target="_blank" rel="noopener noreferrer">long you can be in the sun safely</a>,<a href="https://www.omnicalculator.com/other/sunscreen" target="_blank" rel="noopener noreferrer"> </a>to the odds of your town having a <a href="https://www.omnicalculator.com/other/white-christmas" target="_blank" rel="noopener noreferrer">white Christmas</a>. It now has a dedicated tool for finding how long it will take you to prep your <a href="https://www.omnicalculator.com/food/turkey-thawing" target="_blank" rel="noopener noreferrer">turkey</a> in time for a socially distanced holiday. The <a href="https://www.omnicalculator.com/food/turkey-thawing" target="_blank">Turkey Thawing Calculator </a>was created by Jagiellonian University cognitive science graduate Maria Kluziak with the help of Wojciech Sas, a Ph.D. candidate in molecular magnetism and nanostructures at the Institute of Nuclear Physics in Poland. </p><p>The fundamental problem is that you need to add heat to the frozen bird to unfreeze it without also encouraging the growth of bacteria. To do this, you have to put the turkey somewhere where it will heat up slowly and evenly. There is a trick, though; this can take a long time because of the amount of energy involved. Exactly how long you need to spend on it can be hard to determine if you've never done it before. </p><p>This is where practical, day-to-day science comes in. The processes of heating something are well-studied areas of thermodynamics which we use every day. <br> <br> As Kluziak tells Big Think: </p><p>"If you look closely, you'll notice how we're all surrounded by numbers. Yet most of the time people choose to go with their intuition while making day-to-day decisions. We, as scientists and experts in our own fields, are trying to build a world where people make better, more informed decisions backed by concrete science - Using physics to chill drinks, math to find out how much pizza to get, and even calculating how much groceries are enough to survive a quarantine. It works."</p>
So, how do I thaw a turkey?<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDgwNjA0Ny9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTY0NzI3NTQzN30.hr2xv0tzFU_12bA-wwKwBPv0Tou_ZcdMoF1VDlov-0k/img.png?width=980" id="07afc" class="rm-shortcode" data-rm-shortcode-id="522a8b8370fecb9dcb3bf483adea6fa5" data-rm-shortcode-name="rebelmouse-image" />
Credit: Omni Calculator<p> By slowly exposing the turkey to cool air or water, it heats up to a point where the bird is above freezing but not so warm that bacteria will start multiplying. Two of the safe ways to do this stand above all others; you can thaw it in the refrigerator or the sink.<br> <br> Using a refrigerator can take days; the calculator creators suggest a day for every four pounds of bird. Doing it with cold water in the sink is faster, needing only two hours per pound, but requires that you drain and refill the sink with new, cold water every thirty minutes. The ideal temperature during thawing shouldn't exceed 39°F/4°C.</p><p>"In our thawing model, we use a scientific approach, which is based on the use of heat transfer equations," the scientists write. "Since these types of problems are, in general, very complicated, we use some approximations, which allow us to estimate the thawing time with reasonable accuracy. As a result, you can see how the average temperature of the turkey changes in time." </p><p>You can learn more about the equations and get tips on using the calculator <a href="https://www.omnicalculator.com/food/turkey-thawing" target="_blank" rel="noopener noreferrer">here</a>. You can also learn why you shouldn't use a hairdryer or a tub full of hot water to do the job. <br> <br> One of the best parts of science is that its findings are often universally applicable. If you understand why something works in one case, you can use it everywhere else. Kluziak reminds us why this might be great for cooking:<br> <br> "The rules that govern the process of thawing are roughly the same for every kind of food, what's different are the numbers that determine the more specific things like thawing time. The general ideas remain the same regardless of the food, and I would say they are pure common sense. For example, if you're defrosting food, don't do it at room temperature to avoid bacteria - this is true every time!"<strong></strong></p><p><strong> </strong>Whoever said you'd never use the science you learned in high school at home didn't understand how often we use physics—this calculator remind us that it is everywhere. So fear not, ye first-time turkey chefs! Science can help you have your main course and eat it too. </p>