Burnout Among Physicians Compared With Individuals With a Professional or Doctoral Degree in a Field Outside of Medicine - Mayo Clinic Proceedings

Physician burnout has become the 21st Century indicator for physician dissatisfaction. How accurate is that statement comparing physician burnout with executive burnout, CEOs, and the military command structure?

For one thing, the different professions attract far different personalities. The personality traits of a physician are far different than those of attornies or corporate executives.

In the past patients were aware of the challenge of being a 'doctor'.  Today in the 21st century there are now measurements and data points to prove the vulnerability of a physician.

When a patient enters the examination room, how often does the patient wonder, "Is my doctor burned out?" A normal-appearing doctor may be compensating by substance abuse and/or self-medication and may appear to function quite well.

In a study by 

Tait D. Shanafelt, MD
Stanford University, Palo Alto, CA
Christine Sinsky, MD
American Medical Association, Chicago, IL
Lotte N. Dyrbye, MD, MHPE
Mayo Clinic, Rochester, MN
Mickey Trockel, MD, PhD
Stanford University, Palo Alto, CA
Colin P. West, MD, PhD
Mayo Clinic, Rochester, MN

published in the Proceedings of the Mayo Clinic, the authors state,

"Medicine is a demanding profession with a long and arduous training process. Once physicians complete training, they engage in meaningful and professionally fulfilling work. They also typically work long hours and deal with a number of profession-specific challenges (eg, dealing with medical errors, risk of malpractice suits, frequent exposure to human suffering, and a rigorous maintenance of the certification process). In recent years, a host of regulatory changes and the more widespread use of electronic health records have increased clerical burden and changed the nature of the physician’s workday.1 Collectively, these and other challenges contribute to professional burnout, a syndrome characterized by emotional exhaustion, cynicism (depersonalization), and a decreased sense of efficacy.2

Since 2011, we have conducted a series of studies evaluating the point prevalence of burnout among physicians as well as US workers in other fields.3, 4, 5 These studies have consistently found physicians to be at higher risk for burnout than workers in other fields, even after adjusting for age, sex, relationship status, and work hours. Notably, although increasing levels of education have a protective effect on the risk of burnout among workers in general, this is not true of physicians.3

Although we have previously reported associations between the level of education and the risk of burnout, we have not previously performed a focused analysis comparing physicians with individuals with a professional (eg, JD) or doctoral level (eg, Ph.D.) degree in another discipline. Although the precise nature of their work may differ, these professionals have an educational journey more analogous to that of physicians and may have a more similar set of expectations with respect to work hours and responsibility.

Since 2011, we have conducted a series of studies evaluating the point prevalence of burnout among physicians as well as US workers in other fields.3, 4, 5 These studies have consistently found physicians to be at higher risk for burnout than workers in other fields, even after adjusting for age, sex, relationship status, and work hours. Notably, although increasing levels of education have a protective effect on the risk of burnout among workers in general, this is not true of physicians.3
Although we have previously reported associations between the level of education and the risk of burnout, we have not previously performed a focused analysis comparing physicians with individuals with a professional (eg, JD) or doctoral level (eg, Ph.D.) degree in another discipline. Although the precise nature of their work may differ, these professionals have an educational journey more analogous to that of physicians and may have a more similar set of expectations with respect to work hours and responsibility.

To explore this, we used data from our 2017 survey of physicians and US workers in other fields.5 The methods for this study have been described previously. Among the 5198 employed US workers in the study, 285 (5.5%) had a professional degree or doctoral-level degree in a field outside of medicine. A comparison of the demographic characteristics, work hours, satisfaction with work-life integration (WLI), and symptoms of burnout among these individuals and the 3971 employed physicians in the study from the same age range (age, 29-65 years) is shown in Table 1. Physicians worked more hours per week, were less satisfied with WLI, and were more likely to experience symptoms of professional burnout. The higher rates of burnout and decreased satisfaction with WLI in physicians persisted in a multivariable analysis adjusted for age, sex, relationship status, and hours worked per week (Table 2).

Table 1

Comparison of Employed Physicians in the Sample Aged 29 to 65 y With Employed US Adults Aged 29 to 65 y With a Doctoral Level Degree in a Field Outside of Medicinea

Characteristic Physicians (n=3971) Adults with a PhD/doctoral degree outside of medicine (n=285) P value

Sex
 Male 2279 (57.5) 158 (55.4) .47
 Female 1674 (42.2) 127 (44.6)
 Other 11 (0.3) –
Age
 Median 50.0 51.0 .51
Relationship status
 Single 498 (12.7) 55 (19.3) <.001
 Married 3233 (82.2) 203 (71.2)
 Partnered 168 (4.3) 20 (7.0)
 Widowed/widower 35 (0.9) 7 (2.5)
 Missing 37 0
Hours worked per week <.001
 Mean ± SD 52.6±16.1 44.5±11.7
 Median 50.0 40.0
 <40 h="" span="" style="white-space: pre;">
569 (14.6) 43 (15.1) <.001 40-49 h 801 (20.5) 140 (49.3)
 50-59 h 1017 (26.0) 65 (22.9)
 60-69 h 887 (22.7) 26 (9.2)
 70-79 h 323 (8.3) 7 (2.5)
 ≥80 h 309 (7.9) 3 (1.1)
 Missing 65 1

Distress

Burnout
Emotional exhaustionb P.001
Never 473 (12.0) 29 (10.2)
A few times a year 863 (21.9) 68 (23.9)
Once a month or less 553 (14.0) 59 (20.7)
A few times a month 618 (15.7) 57 (20.0)
Once a week 390 (9.9) 21 (7.4)
A few times a week 585 (14.8) 33 (11.6)
Every day 462 (11.7) 18 (6.3)
Missing 27 0
% High scorec 1437 (36.4) 72 (25.3) <.001

Depersonalization .46
Never 1435 (36.4) 119 (41.8)
A few times a year 917 (23.3) 67 (23.5)
Once a month or less 462 (11.7) 32 (11.2)
A few times a month 417 (10.6) 29 (10.2)
Once a week 209 (5.3) 12 (4.2)
A few times a week 299 (7.6) 14 (4.9)
Every day 199 (5.1) 12 (4.2)
Missing 33 0
% High scored 707 (18.0) 38 (13.3) .05
Burnoute 1566 (39.8) 82 (28.8) P;.001
 
Satisfaction with work-life integration
Work schedule leaves me enough time for my personal/family life:
Strongly agree 422 (10.7) 58 (20.4) <.001
Agree 1157 (29.3) 103 (36.3)
Neutral 641 (16.2) 55 (19.4)
Disagree 1103 (27.9) 57 (20.1)
Strongly disagree 626 (15.9) 11 (3.9)
Missing 22 1







Burnout Among Physicians Compared With Individuals With a Professional or Doctoral Degree in a Field Outside of Medicine - Mayo Clinic Proceedings: range

UPDATE: The FDA Warns that Biotin May Interfere with Lab Tests: FDA Safety Communication | FDA

It is important for patients and providers to know what nutritional supplements, vitamins and other health foods you consume.  Many cross-react with other medications, and/or interfere with standard blood tests. Some of these reactions, side effects are uncommon. You should also consult with your pharmacist. Bring the actual bottle or container to your pharmacy. The ingredients are listed on the container label..

The FDA released a safety communication alerting patients and physicians about the possible reaction from Biotin to laboratory tests. Biotin

The U.S. Food and Drug Administration (FDA) is updating our 2017 safety communication to remind the public, health care providers, lab personnel, and lab test developers that biotin, often found in dietary supplements, can significantly interfere with certain lab tests and cause incorrect results that may go undetected. The FDA wants to make the public and health care providers aware about biotin interference with lab tests so that patients, physicians, and laboratories can work together to help prevent adverse events.

As noted in the original safety communication, while biotin in patient samples can cause falsely high or falsely low results, depending on the type of test, the FDA is particularly concerned about biotin interference causing a falsely low result for troponin, a clinically important biomarker to aid in the diagnosis of heart attacks, which may lead to a missed diagnosis and potentially serious clinical implications. The FDA continues to receive adverse events reports indicating biotin interference caused falsely low troponin results.

Since the FDA's safety communication on this topic in 2017, some lab test developers have been successful at mitigating the biotin interference of their assays, but others have not yet addressed it. The FDA remains concerned about troponin laboratory tests that have not addressed the risk of biotin interference. The FDA has posted a webpage on Biotin Interference with Troponin Lab Tests - Assays Subject to Biotin Interference to notify the public about troponin assays where the risk of biotin interference has not yet been addressed.

Recommendations for Consumers
Talk to your doctor if you are currently taking biotin (also called vitamin B7) or are considering adding biotin, or a supplement containing biotin, to your diet.
Know that biotin is found in multivitamins, including prenatal multivitamins, biotin supplements, and supplements for hair, skin, and nail growth in levels that may interfere with laboratory tests.  However, the amount of biotin can vary significantly among different products. Consider that the daily recommended allowance for biotin is 0.03 mg and that amount does not typically cause interference in lab tests
Be aware that some supplements, particularly those labeled to benefit hair, skin, and nails, may have high levels of biotin, which may not always be clear from the name of the supplement. FDA is aware of many supplements containing 20mg of biotin, and some containing up to 100mg per pill, with recommendations to take multiple pills per day. Supplements containing high biotin levels may interfere with affected lab tests.
Sufficient information is not available to know if stopping biotin consumption for any number of hours prior to testing will prevent incorrect test results.
If you had a lab test done and are concerned about the results, talk to your health care provider about the possibility of biotin interference.
For more information, see NIH Biotin Fact Sheet for Consumers
Recommendations for Health Care Providers
Talk to your patients about any biotin supplements or multivitamin supplements they are taking that may contain biotin, including supplements marketed for hair, skin, and nail growth.
Know that biotin is found in multivitamins, including prenatal multivitamins, biotin supplements, and dietary supplements for hair, skin, and nail growth in levels that may interfere with lab tests.
Be aware that many lab tests, including but not limited to cardiovascular diagnostic tests and hormone tests, that use biotin technology are potentially affected, and incorrect test results may be generated if there is biotin in the patient's specimen.
Communicate to the lab conducting the testing if your patient is taking biotin.
If a lab test result does not match the clinical presentation of your patient, consider biotin interference as a possible source of error.
Report to the lab test manufacturer and the FDA if you become aware of a patient experiencing an adverse event following potentially incorrect laboratory test results due to biotin interference.
Recommendations for Lab Personnel
If you use assays with biotin technology, be aware that it is difficult to identify samples that contain biotin; therefore, it is important to communicate with health care providers and patients to prevent incorrect test results.
If you are collecting samples in the lab, ask whether the patient is taking biotin or a biotin containing supplement.
Educate health care providers about biotin interference with certain lab tests used in your lab.
Consider that the daily recommended allowance for biotin is 0.03 mg for adults and these biotin levels do not typically cause significant interference. However, supplements containing high biotin levels including those marketed for hair, skin, and nail benefits, may contain up to 20 mg of biotin, and physicians may recommend up to 300 mg per day for conditions such as multiple sclerosis. Biotin levels higher than the recommended daily allowance may cause significant interference with affected lab tests.
Be aware that specimens collected from patients taking high levels of biotin may contain more than 100 ng/mL biotin. Concentrations of biotin up to 1200 ng/mL may be present in specimens collected from patients taking up to 300 mg per day.
Currently available data is insufficient to support recommendations for safe testing using affected tests in patients taking high levels of biotin, including about the length of time for biotin clearance from the blood.
Communicate with the lab test manufacturer if you have questions about biotin interference.
Be aware of certain troponin assays where the risk of biotin interference has not yet been addressed. See Biotin Interference with Troponin Lab Tests - Assays Subject to Biotin Interference.
Recommendations for Lab Test Manufacturers and Developers

If your assay uses biotin technology, contact the FDA to discuss biotin interference.
Investigate interference from biotin (up to at least 1200 ng/mL biotin) in your assays that use biotin technology. Determine the lowest concentration of biotin that may cause clinically significant interference with your test(s). Communicate with your customers if they may be unaware that your test uses biotin technology and how it may be affected.

Contact the FDA if you have any questions about biotin technology and interference.

Biotin Interference with Certain Lab Tests May Lead to Incorrect Test Results
Many lab tests use biotin technology due to its ability to bond with specific proteins which can be measured to detect certain health conditions. For example, biotin is used in hormone tests and tests for markers of cardiac health like troponin. Biotin, also known as vitamin B7, is a water-soluble vitamin often found in multivitamins, prenatal vitamins, and dietary supplements marketed for hair, skin, and nail growth.

Biotin in blood or other samples were taken from patients who are ingesting high levels of biotin in dietary supplements can cause clinically significant incorrect lab test results. The FDA continues to see reports of adverse events, in addition to the one death reported prior to the 2017 safety communication, related to biotin interference with lab tests.

Incorrect test results may lead to inappropriate patient management or misdiagnosis. For example, a falsely low result for troponin, a clinically important biomarker to aid in the diagnosis of heart attacks, may lead to a missed diagnosis and potentially serious clinical implications. Prior to the 2017 safety communication, the FDA had received a report that one patient taking high levels of biotin died following low troponin test results when a troponin test subject to biotin interference was used.

The FDA is aware of people taking high levels of biotin that would interfere with lab tests. Many dietary supplements promoted for hair, skin, and nail benefits contain biotin levels up to 650 times the recommended daily intake of biotin. Physicians may also be recommending high levels of biotin for patients with certain conditions such as multiple sclerosis (MS). Biotin levels higher than the recommended daily allowance may cause interference with lab tests.

Patients and physicians may be unaware of biotin interference in laboratory assays. Even physicians who are aware of this interference are likely unaware as to whether, and how much biotin, patients are taking. Since patients are unaware of biotin interference, patients may not report taking biotin supplements to their physicians and may even be unaware they are taking biotin (for example, when taking products generally labeled for their benefits to hair and nails).

FDA Actions

On November 28, 2017, the FDA issued a Safety Communication, The FDA Warns that Biotin May Interfere with Lab Tests, that discussed concerns with biotin interference in certain laboratory tests.

On November 5, 2019, the FDA published this updated Safety Communication because the FDA remains concerned about certain laboratory tests that have not addressed the risk of biotin interference.

In addition, the FDA also published a webpage Biotin Interference with Troponin Lab Tests - Assays Subject to Biotin Interference to notify the public about troponin assays.  (The detection of a rise and/or fall of cardiac troponin (cTn) plays a key role in the earlier diagnosis of myocardial infarction (MI). Cardiac troponins are markers of myocardial necrosis, and, because of their high cardiac-specificity, are the preferred biomarker for the diagnosis of MI.) where the risk of biotin interference has not yet been addressed. 

The FDA continues to monitor reports of adverse events associated with biotin interference with laboratory tests and will update the public if significant new information becomes available.









UPDATE: The FDA Warns that Biotin May Interfere with Lab Tests: FDA Safety Communication | FDA: The U.S. Food and Drug Administration (FDA) is updating our 2017 safety communication.

AMA says Walmart “refusal to fill” policy interferes with the practice of medicine

Recent concerns about opioid misuse and abuse have led payors, policymakers and retail pharmacies to attempt to restrict the dispensing of prescribed opioid dosage and duration.

One such policy of great concern is Walmart’s corporate policy that limits opioid prescriptions to seven days or 50 morphine milligram equivalents, which is causing harm to patients with acute, palliative, cancer-related, chronic pain and other medical conditions requiring amounts or doses greater than the policy allows. 

Walmart is inappropriately interpreting the Center for Disease Control (CDC) guidelines for prescribing opioids to set these policies. Such arbitrary prescribing thresholds interfere with the patient-physician relationship, physician practice and patients’ access to quality care and treatment.

In some cases, physicians have been inexplicably “blacklisted” where Walmart refuses to fill their prescriptions for controlled substances without explanation, and the physicians are left without a means of contesting the decision.

Walmart in explaining it's policy

On multiple occasions, AMA has requested that Walmart be transparent by explaining the algorithm it uses to justify restrictions to prescriptions, but according to AMA, all of its  letters have gone “without a meaningful response.”  As part of continued efforts to resolve the issue with Walmart, the American Medical Association (AMA) sent a letter to Thomas Van Gilder, M.D., Chief Medical and Analytics Officer for Walmart, Inc. on September 24, 2019, regarding its corporate prescription opioid restriction policy, also referred to as its “refusal to fill” policy.

 “Your ‘refusal to fill‘ policy also has disrupted legitimate medical practices that receive form letters telling them their prescribing rights under state law will be superseded by a Walmart-created algorithm that deems a physician unfit to prescribe,”

This is not an isolated occurrence. It follows on the actions of the DEA to decrease opioid prescription negligence by providers. The number of opioid prescriptions has decreased markedly due to education efforts by the DEA and education in alternatives to opioids for pain management.

Undoubtedly a corporate decision was made by Walmart that it could be held liable for overdoses by patients. Usually when a pharmacist questions a prescription he/she contacts the physician directly. The danger of computer algorithms acting

The CDC released an advisory in regarding to their guidelines for opioids.   CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain

Some policies, practices attributed to the Guideline are inconsistent with its recommendations







AMA says Walmart “refusal to fill” policy interferes with the practice of medicine: Recent concerns about opioid misuse and abuse have led payors, policymakers and retail pharmacies to attempt to restrict the dispensing of prescribed opioid dosage and duration.

Suicide rate for kids ages 10 to 14 nearly tripled in last decade: CDC -

The suicide rate among children aged 10 through 14 has nearly tripled from 2007 to 2017, while the suicide rate among older teenagers has increased by 76% between 2007 and 2017, new federal data show.

Meanwhile, homicide ranked as the third most common cause of death for teens aged 15-19 and adults aged 20-24, and the fifth most common cause for children aged 10-14.

“After a stable period from 2000 to 2007, suicide rates for persons aged 10-24 increased from 2007 to 2017, while homicide rates increased from 2014 to 2017,” the report explains.

“The pace of increase for suicide was greater from 2013 to 2017 (7 percent annually, on average) than from 2007 to 2013 (3 percent annually).”

Although it declined from 2000 to 2007, the suicide rate for children ages 10 through 14 has nearly tripled from 2007 (0.9 deaths per 100,000 persons) to 2017 (2.5 deaths per 100,000 persons).

Though stable from 2000 to 2007, the suicide rate for U.S. adolescents aged 15 to 19 increased from 6.7 per 100,000 persons in 2007 to 11.8 per 100,000 persons in 2017. The pace of increase was greater from 2014 to 2017 with an increase of 10 percent per year on average.

“Not only is suicide trending upward, but the pace of increase is actually accelerating,” said the report’s co-author, Sally Curtin, in an interview with NPR.

“It is important to recognize that suicide is not caused by one single factor but instead a range of factors that include mental health conditions, but also include important situational factors that many of us will experience in a lifetime — including social, physical, emotional or financial issues,” Carr was quoted as saying.

Factors such as a reduction in quality of life, the poor job market for college graduates, political polarization, an overload of information due to internet usage, and the effects of social media. Other factors such as prolonged immobility and lack of exercise coincident with the increasing use of the internet.

Glenn Thomas, a clinical director of community-based services for behavioral health at the Nationwide Children’s Hospital in Ohio, told CBS News that the rates of depression have increased consistently with the suicide rate.

Suicide was the 10th most common cause of death among all Americans in 2017.





The suicide rate for kids ages 10 to 14 nearly tripled in the last decade: CDC - The Christian Post:

If you are a fruitfly stay away from the light......It may shorten your life

https://tinyurl.com/yy95675k


Daily blue-light exposure shortens lifespan and causes brain neurodegeneration in Drosophila

Light is necessary for life, but prolonged exposure to artificial light is a matter of increasing health concern. Humans are exposed to increased amounts of light in the blue spectrum produced by light-emitting diodes (LEDs), which can interfere with normal sleep cycles. The LED technologies are relatively new; therefore, the long-term effects of exposure to blue light across the lifespan are not understood. We investigated the effects of light in the model organism, Drosophila melanogaster, and determined that flies maintained in daily cycles of 12-h blue LED and 12-h darkness had significantly reduced longevity compared with flies maintained in constant darkness or in white light with blue wavelengths blocked. Exposure of adult flies to 12 h of blue light per day accelerated aging phenotypes causing damage to retinal cells, brain neurodegeneration, and impaired locomotion. We report that brain damage and locomotor impairments do not depend on the degeneration in the retina, as these phenotypes were evident under blue light in flies with genetically ablated eyes. Blue light induces expression of stress-responsive genes in old flies but not in young, suggesting that cumulative light exposure acts as a stressor during aging. We also determined that several known blue-light-sensitive proteins are not acting in pathways mediating detrimental light effects. Our study reveals the unexpected effects of blue light on fly brain and establishes Drosophila as a model in which to investigate long-term effects of blue light at the cellular and organismal level.

Natural light is essential for the entrainment of circadian clocks, which leads to temporal coordination of physiology and behavior. However, emerging evidence suggests that increased exposure to artificial light is a risk factor for sleep and circadian disorders.1,2 With the prevalent use of LED lighting and device displays, humans are subjected to increasing amounts of light in the blue spectrum since commonly used LEDs emit a high fraction of blue light, often peaking at 460 nm (these lights appear white due to the addition of broad-spectrum yellow garnet phosphor).3 Blue light may affect human eyes,4 and recent data suggest that extraocular light may impact human brain physiology.5 However, the consequences of daily exposure to blue-enriched light across the lifespan are not known.

Laboratory study of drosophila melanogaster

Flies are used extensively to understand the mechanisms of aging in laboratories across the world, but the specifics of light conditions in terms of intensity and spectral composition are usually not provided. Our study suggests that the light used in fly facilities may critically affect experimental outcomes and should be reported in aging studies to facilitate the consistency of the results coming from different labs. Our discovery that lifetime exposure to artificial light may cause extra-retinal damage and reduce longevity in a complex model organism provides a novel opportunity to understand the molecular mechanisms of the increasingly evident harmful side of light.


This was a good scientific method with data for analysis.  The results seem to confirm the posit of the article.  However is this data relevant to primates or humans.?

Such is the  challenge of translating animal studies to humans.

What is the problem, exactly?

Galen Senior Fellow Doug Badger and Heritage Research Fellow Jamie Bryan Hall shed new light on the core problem that health policy experts have focused on for decades—covering the uninsured.

Badger and Hall find, based upon their analysis of Census Bureau data, that “More than 99 percent of Americans have access to health coverage, regardless of their income or medical condition.” 

                                                                                         A doctor speaks to patients at his office in Peoria, Ill., in 2013. (Jim Young/Reuters)

A topic for political disagreements, discussion,  and solutions, access to health care,  in the United States is broken down in this article. (one of the best, I have read, and one I would recommend to any Senator or Congressman.  I am relatively certain that few know the details. The problem lies in the education of the public. 

Please pass it on.

“Millions remain uninsured, not because the federal government is doing too little, but because it is doing (and spending) a lot and doing it badly” including getting people already eligible enrolled, they write. 

Policymakers would do well to focus on solving the problem for this one percent—the uninsured—rather than turning our whole health sector over to the federal government, as many are advocating. 

The recent Census Bureau report on the uninsured overlooked an important point: More than 99 percent of Americans have access to health coverage, regardless of their income or medical condition.

The overwhelming majority of those lacking insurance could have obtained coverage but did not enroll.

Many of those with lower incomes may not sign up for subsidized coverage because they know they can receive care at little or no cost to themselves even if they remain uninsured until they arrive at a clinic.

Those in the top two income quintiles may remain uninsured because government intervention in health insurance markets has created a menu of unattractive products at unattractive prices.

Either way, Americans across the income spectrum deserve a better approach to health care.

Understanding the challenge

It’s critical that policymakers understand the distinction between lack of coverage and lack of access to coverage.

A Kaiser Family Foundation analysis of last year’s Census Bureau report found that of the estimated
27.4 million non-elderly people who were uninsured in 2017:

6.8 million (25 percent) were eligible for Medicaid or CHIP but not enrolled.
8.2 million (30 percent) were eligible for Obamacare subsidies but did not enroll.
3.8 million (14 percent) declined an offer of employer-sponsored coverage.
1.9 million (7 percent) were not eligible for subsidies because they had income more than four times the federal poverty threshold, which put them in the top two income quintiles.
4.1 million (15 percent) were ineligible for subsidies because they were not lawful U.S. residents. Their situation is a matter to be settled by immigration policy, not health care policy.
2.5 million (9 percent) were under the poverty line but ineligible for federal assistance. They represented just 0.7 percent of the population.
These 2.5 million lawful U.S. residents ineligible for federal assistance lived in states that had not expanded Medicaid eligibility to non-elderly, non-disabled adults with incomes up to 138 percent of the federal poverty level.

Here, it is important to draw a second crucial distinction: between access to coverage and access to care.

These 2.5 million individuals are eligible for free care at 3,000 federally-funded health centers in the non-expansion states and 11,000 nationwide. In addition, all public and non-profit hospitals are required to have programs to provide free or low-cost care to low-income patients. These hospitals can enroll low-income people in Medicaid when they show up for care, which is another reason some Medicaid-eligible people wait until they need to see a doctor sign up for their free coverage.

What is the problem, exactly?

Artificial intelligence for medicine needs a Turing test - STAT

In today's post from STAT I . have included pertinent comments from other readers

Speculation abounds about what artificial intelligence can do for medicine. It's time to put it to the test — perhaps an obesity-related Turing test.

Top 15 Promising AI Applications in Healthcare
By  Shailendra Sinhasane  In 



If you read high-profile medical journals, the high-end popular press, and magazines like Science or Nature, it is clear that the medicalization of artificial intelligence, machine learning, and big data is in full swing. Speculation abounds about what these can do for medicine. It’s time to put them to the test.

From what I can tell, artificial intelligence, machine learning, and big data are mostly jargon for one of two things. The first is about bigger and bigger computers sifting through mountains of data to detect patterns that might be obscure to even the best trained and most skilled humans. The second is about automating routine and even complex tasks that humans now do. Some of these could be “mechanical,” like adaptive robots in a hospital, and some might be “cognitive,” like making a complex diagnosis. Others might be a combination of the two, as in the almost-around-the-corner self-driving cars.

The idea of computers sorting through data and detecting patterns is of great interest for analyzing images like mammograms and colonoscopies, and for interpreting electrocardiograms. But is this really transformative or novel? An early version of digital image analysis and facial recognition was proposed by the polymath Francis Galton in the late 1800s. Likewise, machine reading of electrocardiograms has been occurring since at least the 1960s. There are, of course, issues with AI and machine learning like overdiagnosis and misreads, but the narrative is that eventually more data and technology will solve such problems.

Perhaps, though, IBM’s overselling of Watson to use artificial intelligence to identify new approaches to cancer care is a cautionary tale and reminds us that many things in medicine lack fixed rules and stereotypical features, and so will be hard for AI to solve.

Related: AI startups are racing into drug development. Here’s 5 burning questions about which will survive
Another hope is that AI could somehow rehumanize medicine by improving workflows and replacing the current tidal wave of screen time with face time with patients. Although that could happen, all of the data and associated analytics could also lead to an ever more oppressive version of medical Taylorism and a drive for “efficiency.”

It is possible that technology could free physicians and enhance their interactions with patients, but as the recent move to electronic health records shows, that is far from certain and the economic imperatives of corporate medicine to see more patients, capture more charges, and generate more throughput might just as easily predominate. Regulators will also likely weigh in. And while “Alexa, please refill Mrs. Smith’s statin prescription” seems simple enough, will we — or do we want to — get to “Alexa, please schedule Mrs. Smith with everything she needs for hip replacement”?

I think we need a Turing test for medical artificial intelligence. Such a test, proposed by British mathematician and computer scientist Alan Turing in 1950, can determine if a computer is capable of performing complex functions like a human being. For medicine, the test should be a problem that is currently hard to solve. Here’s one I think would be perfect: create a weight loss plan for patients with severe obesity (a body-mass index of 40 or more) that is as effective as bariatric surgery. This would be a classic non-inferiority trial, in which a new treatment isn’t less effective than one already in use.

Obesity treatment as a test of medical AI has the advantage of an easily measured outcome — all you need is a scale — and a condition that is potentially treatable by one or more interventions. Surgery is effective for sustained weight loss, and there are good data on the most effective surgical approaches. But it isn’t the only option — some people achieve long-term weight loss without surgery. Class 3 obesity is a common condition with plenty of downstream hazards — including increased risk of developing diabetes, heart disease, cancer, and arthritis, as well as trouble with activities of daily living — so the ability to recruit motivated participants for a randomized trial should be relatively easy.

All sorts of data are available that could be fed into “the computers” to generate individualized plans for participants. Beyond simple demographics, the plans could also synthesize genetic data, diet and exercise preferences, and information from wearables. Text messages could be sent to remind people what foods to avoid or when they needed to get in more steps for the day. Shopping for food could be automated, and certain foods and portions sizes at restaurants could be made electronically off limits. Even better, customized menus could be constructed on demand. All of this could be linked to financial incentive programs.

Related: IBM pitched its Watson supercomputer as a revolution in cancer care. It’s nowhere close
If you really wanted to stretch the limits, cars could be programmed to make it difficult to stop at fast-food restaurants. Or some sort of “pre-eating” aversive stimulus could be applied when the algorithm detected signals or subtle behaviors associated with an increased likelihood of excessive eating — depending, of course, on ethical committee approval.

In short, it’s entirely possible to develop a truly comprehensive weight-loss plan.

The fact that genetic data, diet preferences, wearables, and text messages don’t seem to have much impact on long-term weight loss in controlled trials are only minor details. There are also a host of issues with implementing artificial intelligence in the real world. But let’s not get distracted.

Enthusiasts of AI, machine learning, and big data should throw caution to the winds and craft a highly effective alternative to bariatric surgery. Such a demonstration would clearly tip the scales and show the skeptics what medical AI can do.

Or put more simply: It is time for medical artificial intelligence to go big or go home.

Michael J. Joyner, M.D. is an anesthesiologist and physiologist at the Mayo Clinic. The views in this article are his own.

About the Author
Michael J. Joyner
@DrMJoyner

Top 15 Promising AI Applications in Healthcare
By  Shailendra Sinhasane  In  Blog  Posted  June 17, 2019
Tags
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Donna Lemons
SEPTEMBER 6, 2019 AT 5:26 AM
Well written Michael!! AI has the potential to be applied in almost every field of medicine including drug development, patient monitoring, and personalized patient treatment plans. The healthcare industry is evolving rapidly with large volumes of data and increasing challenges in cost and patient outcomes. So, early adaptation of AI in the healthcare space is necessary. I have found some articles very informative on this topic these are: https://www.navedas.com/real-world-examples-of-ai-and-healthcare-in-action/ and http://sitn.hms.harvard.edu/flash/2019/artificial-intelligence-in-medicine-applications-implications-and-limitations/








Artificial intelligence for medicine needs a Turing test - STAT:

Predictions for Price Increases in Pharma for 2019

https://www.vizientinc.com/-/media/documents/sitecorepublishingdocuments/public/july2019dpf_slides_summary_public.pdf


https://www.vizientinc.com/-/media/documents/sitecorepublishingdocuments/public/july2019dpf_drugpriceforecast_public.pdf

One of the most driving forces for increasing health care costs in the United States is the cost of pharmaceuticals.  If you compare drug prices in the U.S. with the U.K. E.U., Mexico or South American countries there is a great disparity.

Increases in drug prices cannot be compared using overall global prices when there is actually much price variation when looking at specific drug classes. There are large fluctuations in price when pharma companies are merged, or purchased by venture companies who anticipate great demand for a product.  Some well-known brand pharmaceutical manufacturers have disappeared from the market place.  Not all companies make huge profits.  Some companies barely make a profit, if any.

There are many orphan drugs on which companies lose fortunes. Then there are companies in the news which make huge profits. such as Purdue, the manufacturer of Oxycontin.

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The expansion of smart health communities |

Industries are catching on to the inefficiency of data silos.  Health care is its own silo. Expanded connectivity and the exponential growth of technology are enabling smart health communities, which could offer a modern take on community-based well-being and disease prevention.

Five core components industry and government stakeholders can consider in the shift to health and well-being

Expanded connectivity and the exponential growth of technology are enabling smart health communities (SHC), which could offer a modern take on community-based well-being and disease prevention. 

HISTORICALLY, health care was delivered in the community. Physicians made house calls; birth and death happened inside the home. As the modern hospital developed, health care migrated inside its walls. Meanwhile, the concept of health became increasingly medicalized, and separated from people’s daily lives.

One example of an SHC is the YMCA’s decades-old National Diabetes Prevention Program (DPP), which uses the community to encourage individuals to proactively manage their weight and exercise with a coach in a group setting based at a local YMCA. While successful, these programs have had limited reach since they are tied to brick-and-mortar locations and require individuals to participate in person. 

THE FIVE KEY ELEMENTS OF A SMART HEALTH COMMUNITY

Digital technologies have the potential to significantly bring these programs to scale, thus increasing their impact. The widespread use of smartphones—which are prevalent even in lower-income communities—can increase the potential for virtual programs to scale widely. Apps on these phones can incorporate concepts from the behavioral sciences, such as nudges and gamification, to help people stay on track with their health care goals. 

The recently relaunched WW International (formerly Weight Watchers International), which now uses a technology platform to create a virtual community focused on weight loss and wellness and is informed by the science of behavior change, is an example of an SHC that is leveraging technology effectively.

A significant body of research shows that about 80 percent of health outcomes are caused by factors unrelated to the medical system. Our eating and exercise habits, socioeconomic status, and where we live have a greater impact on health outcomes than health care.

The pendulum is now swinging back to the community. Nontraditional players, including public, nonprofit, and commercial enterprises are establishing “communities” focused on prevention and well-being. These communities can be geographically based local initiatives, virtual communities with a global presence, or hybrids of the two.

The Deloitte Center for Health Solutions and the Deloitte Center for Government Insights interviewed over a dozen leaders from prevention and well-being initiatives outside of our traditional medical system to learn about the characteristics that are essential to their mission. These interviews have contributed to the development of a concept we call smart health communities (SHCs), which we define as containing some or all the following core features:


They empower individuals to proactively manage their health and well-being;

They foster a sense of community and belonging;

They use digital technology and behavioral science;

They use data to meaningfully improve outcomes; and

They create new and innovative ecosystems.

The dramatic changes reshaping health care today are driven in part by the intersection of Metcalfe’s Law and Moore’s Law. 

Metcalfe’s Law describes how the value of a network escalates dramatically as membership increases. Moore’s Law describes how computing power doubles roughly every two years. In tandem, these two phenomena will likely allow SHCs to grow and become more sophisticated, interconnected, and influential over time. 

                                  Metcalfe's Law

As this happens, the impact of community-based health interventions could be brought to scale, while becoming more personalized. Looking 20 years into the future, technology and other factors may allow more health care to migrate out of institutions and for SHCs to become more integrated into our daily lives, allowing for more preventive and personalized health interventions that can exist alongside—and perhaps even in collaboration with—our existing health care structures.

Smart health communities and the future of health

The expansion of smart health communities | Deloitte Insights:

UnitedHealthcare to Begin New Site of Service Policy

UnitedHealthcare has announced it will begin site of service medical necessity reviews for certain surgeries when surgery is performed in an outpatient hospital setting. In California, the reviews will begin Dec. 1.

The site of service policy is not unique to UHC, and Oxford, Cigna Anthem, and others use the same protocol.

The policy limits the circumstances in which UnitedHealthcare will pay for certain surgeries performed in a hospital outpatient setting, determined by the insurer whether or not the site of service for the procedure is medically necessary. Other states that will see reviews starting on or after Dec. 1 are Colorado, Connecticut, New Jersey, and New York. The policy will not apply to providers in Alaska, Kentucky, Massachusetts, Maryland or Texas.

"Medical necessity reviews for the site of service occur during our prior authorization process and are only conducted if the surgical procedure will be performed in an outpatient hospital setting," UnitedHealthcare said, according to Becker’s Hospital Review. "We utilize our Outpatient Surgical Procedures – Site of Service Utilization Review Guideline to help make our site of service medical necessity determinations. Site of service medical necessity reviews are currently being conducted for certain surgical procedures and will apply to additional surgical procedures beginning on Nov. 1, 2019, for most states."

The number of outpatient facilities jumped from 26,900 to 40,600 (51%) from 2005 to 2016, according to a report from CBRE, a commercial real estate services and investment firm. Along with it, rent has shown a similar trend, setting a record high in the second quarter of 2019, rising 1.4% per year to $22.90 per square foot.

Making services more convenient and more affordable is what it comes down to, said Christopher Bodnar, vice chairman of CBRE Healthcare Capital Markets, according to Modern Healthcare.

"That strategy moves along the entire continuum of care for providers. It's front and center for their real estate strategy as well," Bodnar said. "We are seeing health systems look to decompress their main campus and look to move more services to an outpatient setting."

Hospital outpatient settings typically cost more, due to their increased overhead as a component of an acute hospital

With the outpatient surgery policy, the insurer said it hopes to reduce healthcare spending by guiding patients toward ambulatory surgery centers, where care may be cheaper when there isn't a substantial medical reason for the surgery to be performed in a hospital outpatient setting..

Correlating with this emphasis on freestanding ambulatory surgery centers the number of outpatient facilities surges as industry values more convenient, affordable care  systems are looking to keep pace with mergers like CVS Health and Aetna and Optum's continued push into the market, drawing patients away from the hospital into a retail setting, closer to where people live and shop to fulfill the demand of more accessibility. 

The number of outpatient centers increased by 51% from 2005 to 2016, a trend that shows no sign of slowing.  The number of outpatient facilities jumped from 26,900 to 40,600 between 2005 and 2016, according to a new report from commercial real estate firm CBRE. Rents have followed. They reached a record high in the second quarter of this year, rising 1.4% year over year to $22.90 per square foot, driven by areas with low vacancy rates like Louisville, Ky., Seattle, Nashville, Manhattan, and Indianapolis.

It mainly comes down to two things: making services more convenient and more affordable, said Christopher Bodnar, vice chairman of CBRE Healthcare Capital Markets."Technology is also changing so fast that providers can bring care to the consumer quicker and in a different way," Mark Lamp, executive managing director of healthcare at CBRE said. "Providers recognize that they need to deliver care differently than they have in the past."

Some hospitals partner with other real estate ventures to lower cost and add value.

Rush University to outsource facility management, illustrating a trend

Source:  https://tinyurl.com/y4mtfajz

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