Sunday, March 11, 2012

The Value of Travelling Medicine

After many years of hard work and preparation, I finally have a chance to do what I have wanted since starting down the road of Medicine--innovate in Primary Care.  And a long road it has been!

Due to some unavoidable circumstances around physician staffing, my current work with Iora Health has offered me a chance to practice Primary care in our first open clinic, the Culinary Extra Clinic in Las Vegas, Nevada.  As some of you may know, I currently consider Boston my home, a vexing situation.  What we have worked out (we being my wife and my company), is for me to travel to and from Las Vegas weekly,  spending 3-4 days practicing primary care in our brand new and frankly amazing practice.  By Boston academic standards, this actually has me at full time (8 "sessions" per week, where one "session" is one half-day).  The road is long, the travel tiring, and the time away from my wife unbearable.  However, I have learned something about travelling to a single to location to work that my younger colleagues may wish to consider.

No matter where you do it, the practice of primary care can be consumptive.  Each patient has unique needs, often with much deferred self-care over the years, and in the presence of a supportive primary care system, the "work" to be done is staggering.  While my work as a physician is to recognize disease, help to prescribe and decide a path to health, and guide my patients as they walk--the real work lies with each individual to care for themselves and their family.  In any case, the days are long and the work both inspiring and tiring.  Now add to that the prospects of launching a brand new practice, as part of a larger, new company.  As you can imagine there is plenty to do. And I am grateful that I get to do it on the road.

Strange? Surely.  I had no idea that the travel would help.  It turns out that being stuck in a different city (and Las Vegas is certainly different from Boston), is incredibly beneficial when faced with the prospect of hard work.  While I miss my wife terribly, there is no signal other than hunger or fatigue that my day's work is done.  I have no plans, no friends calling me to go out, no obligations.  While this would be a sad existence in the long term, when faced with such monumental mountains of labor, I find it... comforting.

The ability to focus singly on one task is a gift in some ways.  It is certainly a privilege that I did not enjoy as a resident--always pulled in a million directions at work while simultaneously seeking the elusive and ill-defined "work-life balance."  But, if you can believe it, in Vegas there are no distractions.  I wake up, work out, work all day, eat dinner, work all night, sleep and repeat.  I am honing my craft and although the costs are high, I believe the rewards will be as well.

So some advice to my younger colleagues:  Get out there.  You either have been or are currently struggling in some type of race through medical school, residency, or the ranks of junior faculty.  You are trying to make a life for yourself in your chosen home town and all of its attendant benefits.  I implore those among you who can, to consider hitting the road for awhile.  Move some place different, commute far to work and really dive in to it.  The rewards will shock you.*

* I have only been doing this for 3 months, I will have more complete data in 3 more.

200 Pages on Diabetes, 1 paragraph on food supply

Sorry for the hiatus... you would think all of the plane travel to and from Las Vegas would give me plenty of time to write.  I do have some ideas that I have stored away and I hope to get them out in the next few hours to days.

Constant flying has afforded me one unique opportunity--the necessary need to disconnect from screens (iPhone/iPad/Mac Book Air) for just a few minutes when we are taking off.  Although the evidence around this policy is shoddy at best, I have learned to pack real live printed materials to entertain me during the endless waiting between sitting down and plugging back in.  Most often, journals such as Health Affairs or the New England Journal of Medicine fill this time.

The January issue of Health Affairs, a well-respected, in-depth monthly look at health policy research and proposal, focused on Diabetes as the theme for the issue.  As usual, a collection of well-thought out and well-intentioned articles fill the pages of this journal, examining the effects of existing laws and programs, and proposing new, population wide strategies to combat disease and improve health.  Prominent among the articles were suggestions of financial incentives (or taxes) on certain individual behaviors to promote a lifestyle that would avoid diabetes.  The usual suggestions of taxing sodas to save the world were laid forth. What struck me the most about this issue was not what was suggested, but what was ignored--the food supply.

In the typical policy attempt to draft smarter and better regulations to more adeptly mold human behavior to fit some vision or another, new laws and new restrictions are always proposed.  In an almost comically predictable fashion, there is almost zero evaluation of previous programs or policies with the same intended consequences, and even more sparingly, evaluation of seemingly unrelated laws with disastrous consequences.  In this case, in over 200 pages on proposals for policy changes on diabetes, I could find only 1 paragraph discussing the laws that govern our food supply.

One paragraph.

While Diabetes is a multifactorial condition (code for we have some great ideas but no clear mechanism of disease), it is indisputably linked to food consumption.  There is a stark correlation between changes in the American (and subsequently the world) food supply towards corn and corn-derived food sweeteners and a shocking increase in diabetes.  (Again, correlation, not causation).  So why go after corn?  It turns out that the reason for the shift away from sugar to corn is the result of, you guessed it, former public policy decision in the United States.  I am not talking about health regulations, but about farm subsidies.

It is US Agricultural policy that determines that corn is cheap and plentiful, and its derivatives fill our groceries stores and stomachs.  Does this cause diabetes? I do not have convincing evidence, but enough suspicion to voluntarily choose to avoid the stuff whenever possible and advice friends, family and patients to do the same. To be honest, ever since we covered how well the body regulates glucose metabolism vs. fructose metabolism, I have been convinced that this stuff is at least undesirable.

Farming politics and Biochemistry aside, I always find it frustrating that the solution to the unintended consequences of one law is to prescribe more laws.  As a physician I am guilty of the same, often using one medicine to counteract the effects of another (breaking Solomon's Law of Pharmacology).  Not to excuse my own behavior, but there are very few drugs out there and I have no ability to modify any of them.  Stark contrast to our political and regulatory system, which as the ability to modify and improve itself retroactively but chooses to do so only through new prescriptions.

While I applaud my colleagues efforts at applying their skill set to what is a broad and complex problem, I would caution all current and future policy makers to consider the effects of what your predecessors have done before jumping into the dance yourself.  Perhaps the next time Health Affairs covers diabetes, they can look back at undoing causes instead of proposing to limit individual freedoms to make up for errors at the policy level.