Food Reward Friday

This week's lucky "winner"... Lay's milk chocolate-dipped potato chips!!

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Bikini Contest Prep- 6 Weeks Out Progress Update

I went for my bikini consult to order my suit and I'll share that with you next, just off to the gym now and wanted to post my latest progress update. Although things are coming together, and if I hadn't committed to this contest, I'd be very satisfied with where I am now, but I still have lots more work to  do to get "competition ready."  

My body fat is 19% right now, but it only came down from 19.75 in the last two weeks.  We are looking for it to come down at least one point a week, so my trainer was saying he needed to adjust my diet. I had to confess the Cheerios I was eating at night.  He explained that ideally I would lose another 8 pounds before the contest, so every calorie counts and eating carbs right before bed is not a good idea. In fact, he prohibited any carbs after 6 PM from now on. I promised no more Cheerios, and I would instead be drinking my protein shake like I was supposed to.  I've been doing that the last couple days and I am hungry at night, so I've been going to bed earlier. This is actually a good thing because then I wake up more energized in the morning. Eating my meals consistently throughout the day prevents me from getting any midday slump.   

I also admitted to my trainer that I have not been able to give up my coffee creamer. He tried to persuade me against using it but said I could keep using it as long as I only used 1 tablespoon. It's a deal!

I really don't know if I can lose 8 pounds in six weeks,  but I am uping the intensity of my cardio now. I'm making sure to get in five, 45 minute sessions at a more intense rate.  I'm typically on the treadmill and do 15 incline at 2.5-3.0 intervals. This should help me burn more calories. I also measure everything I eat so I know I'm getting precisely the exact amount. I realized one fish filet per meal is not enough, it needs to be one and a half to equal 5 ounces cooked. 

I share all these details with you to let you know exactly what it takes to do something like this and also to chronicle my journey. I really appreciate you following along and your supportive comments. Thank you. 

One of the things I like most about having a trainer to help get me ready for this contest is that I don't have to stress about whether what I'm doing is working.  I can be confident that, if I just follow his directions, I will see changes and results.  When I used to workout before, I was never quite sure if what I was doing was going to get me the best results.  (Should I be doing more cardio?  How much?  Should I lift heavy weights or lighter?  What exactly should I be eating?) It's not easier with the trainer- I still work my tail off, but the mental part is better.  I don't feel like I'm spinning my wheels. 

On another note, Victoria's Secret has the cutest swimsuits lately.  I ordered the one above and 2 other mix and match styles.  Love them!

Have a great Thursday!  It's almost the weekend again!

Godzilla and VA Wait Times.

As predicted, the Veterans Administration (VA) waiting-list fracas is going from bad to worse.  Seeking refuge from all the bad news, the Population Health Blog naturally responded by inviting the spouse to go see the new Godzilla movie in IMAX 3D.

Mysteriously, she declined the invitation. 

Despite the two-plus hours of lonely and noisy cinematic excess, thoughts about the VA still intruded. As a result, the PHB has created another multiple choice test that tests readers' awareness of popular culture and this corner of health care policy. 

Good luck!

"Breaking Bad" actor Bryan Cranston is casted as scientist Joe Brady who barely survives a mysterious catastrophe at a Japanese nuclear plant. Years later, he (select the best answer):
 
1. is convinced that there is a cover-up
2. is still awaiting the report of the Nuclear Administration Inspector General who has yet to find any wrongdoing by anyone who is in charge
3. has an annoying level of anxiety that, in the opinion of the PHB, warrants industrial-strength doses of Xanax

At several key moments in the movie, there are sudden malfunctions of electronic equipment. That's because (select the best answer):

1. of monster-sized electromagnetic pulses
2. they're networked with the VA's computer system that manages wait lists
3. they're not, as the PHB spouse likes to frequently point out, Apple-based products

Godzilla's arch enemies are two large bugs that (select the best answer):

1. have unbalanced the natural order and must therefore be destroyed
2. the White House first learned of when they read the news reports
3. are a couple and - thankfully - were not filmed when the female's eggs were fertilized prior to their implantation in the ceiling of the San Francisco subway system.

Godzilla's rampage results in numerous American military injuries.  That's (select the best answer):

1. because the monster has very big feet
2. OK, because the injured will be able to get care outside of the Veterans Administration health care system
3. the result of the generals failing to heed the lessons of the 1960s Godzilla movies that repeatedly demonstrated tanks and machine guns are to no avail.

At the end of the movie, Godzilla appears to be taking a dirt nap. He (select the best answer):

1. is merely tired and has decided to rest
2. is providing us with a useful reminder us that even prehistoric creatures had to deal with wait-times.
3. awakens when a San Francisco veterinarian ill-advisedly attempts to obtain a nasal biopsy.

Big Data, Definitions and Population Health

What's the likelihood of diabetes?

Utter the term "big data" at any ACO, care management or managed care meeting, and one of two things will happen:

1) Your colleagues will admire your population health chops and your boss will be reminded that you deserve a raise, or

2) Your colleagues will tire of your faddism and your boss will wonder, once again, just what "big data" means

Either way, you may want to refer your colleagues and boss to this readable "on-line first" article appearing in JAMA.

Here's a handy PHB summary:

"Big data" can be defined as the linking of disparate large data sets to provide insight at the individual level.

It's been used by political campaigns (swing voters), business (expectant mothers) and the NSA (potential terrorists). Once they are identified, amenable voters can be individually lobbied, expectant mothers can be sent personalized coupons and evil-doers can be visited by Jack Bauer.

According to Weber and his co-authors, how should health care providers approach big data?

1) Inventory the available data sets.  Traditional examples include electronic health records, insurance claims and pharmacy data.  Big data architects should also be aware of non-traditional examples including social media, census records and credit card purchases (such as grocery store purchases, fitness club memberships or over-the-counter meds).

2) Anticipate "probabilistic matching," since two or more individuals may fulfill criteria.  This will involve trade-offs between accuracy and feasibility, since two individuals matching "John Smith" in a single zip code may appear to have the same risk. 

3) Worry about HIPAA. Unfortunately, while medical data sets are disparate, they're also walled off by privacy concerns and special regulations that govern genetic and mental health data. It's not insurmountable. The health care industry should also participate in the public square to and help shape evolving societal and legislative standards over privacy.

Fortunately, the population health industry (here's a modest example) is already engaged. They understand that big data can be used to estimate individual risk which can, in turn, guide outreach to individual patients.

Image from Wikipedia

Bikini Contest Prep (6 Weeks Out) My Daily Meals

I'm FINALLY in a really good groove with my meals.  Now that I've learned that I can actually season my food, I'm so much happier with the taste!  I (sorta) joked with my trainer/nutritionist that he could have mentioned that about 7 weeks ago!!  I eat the same thing over and over, but since I like it, I don't mind.  I still struggle with my last meal of the day (a protein shake or egg whites with side salad) because at that time of night (about 8pm) I just want a bowl of cereal.  I have caved and had cheerios several times. 

Protein Pancake:  My breakfast is a protein pancake that I eat around 7:30 a.m.  I top it with Molly McButter (butter flakes, also known as manna from Heaven after you haven't tasted butter for so long) and all natural fruit spread (both trainer approved).  My pancake is kind of like dense bread with butter and jelly.  I actually love it now.  I eat it like pizza.

I make my protein pancake with 1/2 cup of ground oats (I buy whole old fashioned oats and grind them in the food processor) with 3/4 cup of All Whites and a splash of water- less than 1/4 cup.  I used to make it with cinnamon and flax seed, but lately, have just been doing the 3 ingredients above.  I make one big pancake in a small skillet.  You flip it when it's just about solid on top.

After the pancake is cooked (I'll touch it to feel that it is firm), I cut it into 4 pieces let it cool on the stove top (or a wire rack) because I found that if I put it directly onto the plate, it was still steaming and got soggy.  

Meals 2, 3, and 4 are 5 oz of fish (mahi mahi), 4 oz of potato, and 1 cup of veggies (green beans or broccoli).  I eat this at about 11:30 a.m.; 3:00 p.m.; and 6:00 p.m.

FISH:  I buy individually wrapped fish fillets and defrost them in the fridge or in a bowl of hot water.  In the bowl of water, they only take about 5 minutes to defrost.  Then, I pat dry, sprinkle with Mrs. Dash and garlic powder and cook on the stove top on medium high heat for about 7 minutes.  I'm careful not to overcook it, and take it off the heat when it's just about cooked through so it's still moist and juicy inside.  This fish is really good and has a mild flavor.  

POTATOES:  I wash and prick with a knife, then microwave for 4-5 minutes.  Then I chop them up and toast them up in a skillet.  After they are browned, I season with Molly McButter.

VEGGIES:  I buy big bags of frozen veggies, measure 1 cup onto a plate and microwave for 3 minutes.  Then, season with Molly McButter.

SALAD:  I can also have salad (no iceberg lettuce) so I use romaine and spinach, with fat free dressing.

PROTEIN SHAKE:  My last meal (around 8:00 p.m.) is usually a protein shake with one scoop of protein and 6 oz of water. 

Until my trainer/nutritionist modifies my meal plan, this is what I'm eating.  Every day, all day.  My husband said he'll do this last month with me (but he'll do chicken and lean red meat instead of fish).  He's seen me lean up and wants to lose some weight too.  

I go for my bikini consult (where I choose my competition suit on Tuesday evening, so I'll be sure to report back about that experience).  Have a great week!

The Two-Sided Iron Triangle of Cost and Access and What It Means for Health Reform in 2015

From time to time, the Population Health Blog likes to refer to this article on the "iron triangle" of health care reform. Using classic project management theory, it suggests health care planning is:

a) bound by 1) cost, 2) quality and 3) access, and

b) if there are limited resources, health system planners can only optimize two out of three.

Want to decrease costs?  Either quality will go down or access to care will decline. 

Want to increase access?  Docs and operating rooms will spend less time with patients (quality will suffer) or costs will go up, because you have to hire more docs or build more operating rooms.

Suppose you want to increase quality?  Because most interventions that increase quality are not free, it'll cost you.  Alternatively, fixed budgets and resources will have to be tasked to additional needs, so access will suffer.

It's admittedly simplistic, but this framework can be used even by the amateurs in the White House to better define the Veteran Affairs scandal. As the PHB understands it, VA administrators wanted to increase quality (more primary care, better mental health services), but they didn't have the budget to match it. Access declined and, voila, waiting lists developed.

Which brings the PHB to the insurers' dilemma.  The generous narrative is that commercial and government insurers can leverage "quality" and somehow increase access for more persons with insurance and/or "bend the curve" of cost inflation.  The "iron triangle" says that's not true and the PHB agrees.

That's because:

1) while it's possible to statistically assess outcomes in primary care settings, there is a shortage of primary care providers.

2) it's far more difficult to statistically assess outcomes in specialty settings, where there are limited numbers of patients, fewer commonly accepted outcomes and a greater impact of patient variation.

In other words, quality is neutralized. That means health care is a two sided triangle.

Assuming quality is now constant, the PHB now has another reason to predict that insurers will have only two options in 2015:

1) increase access to care for more persons, but that means increasing, not decreasing costs. That means higher out-of-pocket costs for patients, or lower reimbursement for providers.

2) lower costs, but that means decreased access to care. Providers will refuse to contract or more restricted provider networks be created.

Image from Wikipedia

Maintenance of Certification in Internal Medicine: What the Population Health Community Needs to Know

Since population health provider organizations work closely with physicians, they're aware that "board certification" is an important credential.  Being "boarded" in family practice, pediatrics or internal medicine is widely regarded as evidence of extensive training.

They may not be aware of the controversy brewing over board certification in the internal medicine physician community.

The American Board of Internal Medicine (ABIM) is the certifying Board for the nation's internists.  After meeting training requirements involving years of training after medical school graduation, candidates have to pass an examination.  Once physicians do that, they have the credential that documents their expertise. 

It used to be that once you did the training and passed the test, you were credentialed as a "board certified" internist.... forever.  With increasing recognition that skills can grow stale with time, in 1990 the ABIM decided to require recredentialing on a periodic basis. 

That process has evolved under the umbrella term "maintenance of certification" ("MOC").  You can read more about that here and here, but it basically involves earning "points" through activities such as documentation of learning, participation in quality improvement, chart audits and taking a repeat test.

Unfortunately, MOC and the ABIM have become a focus of physician ire.  While the academics and organized medical societies' leaders believe in the process, many rank and file practicing physicians disagree. 

Among their concerns that are nicely documented here and here:

1. It takes a considerable amount of time, documentation, and paperwork to complete the 10 years' worth of continued training/chart audits and to prepare for the repeat examination.  (That's especially true thanks to the difficulty at extracting electronic records data; it also puts smaller practices at a disadvantage, since they may not have the support personnel to help with all those tasks).

2. It's also expensive.

3. If a physician doesn't pass the test, it needs to be taken again at additional cost.  Over the past five years, the failure rate has increased from 10% to 22%.  Since it's unlikely that the pool of docs entering the MOC process are dumber, that suggests the test is getting unnecessarily harder. Some physicians wonder if ABIM has a financial incentive to increase the failure rate. 

4. Unlike the initial process of board certification, there is little hard evidence that MOC-credentialed physicians  attain better patient outcomes compared to non-MOC physicians.

5. Physicians are unhappy that the MOC process does not recognize the practical wisdom that comes with decades of patient care.  It is "one size fits all" and can't be tailored to account for different practice settings.

6. There is a possibility that MOC could evolve from a voluntary exercise in professionalism to a mandatory condition of licensure, hospital/insurer participation or employment.

7. ABIM not only has a monopoly, it has no oversight. Whatever the merits, the ABIM's MOC actions are seen by some as capricious, arbitrary, disconnected to the real world and only adding to physicians' low morale.  One survey suggests a majority of practicing physicians are skeptical about the MOC.

 The Population Health Blog suspects this is a controversy that is not going away anytime soon.  Population health service providers will always be interested in helping their "orphan" patients without a PCP become engaged with a physician, and may use "board" status as one criterion for referral.  It remains to be seen if "MOC" participation should be part of that calculus.

Stay tuned!

A New Understanding of an Old "Obesity Gene"

As you know if you've been following this blog for a while, obesity risk has a strong genetic component.  Genome-wide association studies (GWAS) attempt to identify the specific locations of genetic differences (single-nucleotide polymorphisms or SNPs) that are associated with a particular trait.  In the case of obesity, GWAS studies have had limited success in identifying obesity-associated genes.  However, one cluster of SNPs consistently show up at the top of the list in these studies: those that are near the gene FTO.

As with many of the genes in our genome, different people carry different versions of FTO.  People with two copies of the "fat" version of the FTO SNPs average about 7 pounds (3 kg) heavier than people with two copies of the "thin" version, and they also tend to eat more calories (1, 2).  

Despite being the most consistent hit in these genetic studies, FTO has remained a mystery.  As with most obesity-associated genes, it's expressed in the brain and it seems to respond somewhat to nutritional status.  Yet its function is difficult to reconcile with a role in weight regulation: 

• It's an enzyme that removes methyl groups from RNA, which doesn't immediately suggest a weight-specific function.
• It's not primarily expressed in the brain or in body fat, but in all tissues.
• Most importantly, as far as we know, the different versions of the gene do not result in different tissue levels of FTO, or different activity of the FTO enzyme, so it's hard to understand how they would impact anything at all.  

An important thing to keep in mind is that GWAS studies don't usually pinpoint specific genes.  Typically, they tell us that obesity risk is associated with variability in a particular region of the genome.  If the region corresponds to the location of a single gene, it's a pretty good guess that the gene is the culprit.  However, that's not always the case...

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Medical Marijuana and Population Health

Many population health providers may deal with the chronic conditions of HIV, Alzheimer disease, multiple sclerosis cancer, epilepsy, inflammatory bowel disease and mental illness. For those who do, it's only a matter of time until they have to deal with medical marijuana.

Here's a good summary that provides some useful insights:

1) There is precious little peer-reviewed clinical trial data.  Much of the political and regulatory support is based on patient testimonials and the luster of tax revenue. 

2) Dosing is highly variable and dependent on a mix of over a hundred active ingredients, some of which are intentionally manipulated to develop different plant strains.

3) A marijuana pill has been approved by the FDA, but typically goes unmentioned by advocates. Small wonder, since smoking weed allows the user to not only titrate any medical effects, but the euphoria that goes along with them.

4) Absent clinical trial data, short and long term harms are also largely unknown.  There are worrisome reports of structural brain changes, decline in IQ, mental illness and respiratory disease.  Legalization would further increase the public's perception of safety.

5) FDA involvement is minimal.  If contamination occurs (pesticides, herbicides or fungal infestation), there is little hope of a recall.

The authors conclude with the usual academic call for more research.  The Population Health Blog wholeheartedly agrees.

The PHB also predicts the population health vendors and their outcomes registries may become an important factor in better understanding the role of medical marijuana in the management of chronic illness.  In the meantime, an evidence-based approach would suggest that until we have better data, informed skepticism should prevail in the course of patient coaching and decision-making.

Image from Wikipedia

Before & After Success Story (Valerie)

Hearing from readers on similar fitness journeys makes me so happy.  It makes me feel like we're all in this together.  I would love to celebrate you and feature your success story here.  Send me an email at: honeywerehomeblog@gmail.com

via 

Valerie wrote in explaining how she has lost nearly 100 pounds!  Can we take a minute and just let that soak in?? Wow! Talk about a journey that you truly have to take one day at at time.  I am so proud of her and couldn't wait to share her story with you.  I hope this gives encouragement to anyone who wants to lose a significant amount of weight.  I can tell from her face that she is so much happier now that she's a more fit person.  And it wasn't easy for her- she works and has kids with sports activities, so she wakes up at 5:30 a.m. to get her workouts in.  Valerie, big hugs to you girl!  You can visit her blog too- Fabulous Chick Gets Fit and follow her on Instagram IG: @fabchickgetsfit

Age, height, and weight ("before" and "after").  I am 31, 5’4” and my highest weight was 280lbs. Right now I am 189lbs.

Family status- married/single/kids/work?  Other background you wish to share. I am married with two kids {Sydney is 4 and Bryce is 8} I work as an event planner.

"Light bulb moment"- What made you decide to make a change? When I turned 30, I celebrated my birthday in Miami and saw a picture of myself and new I had to change. I was 280lbs and a size 22! I had put myself on the backburner and tried so many fad diets before like so many others. But this time was different. I was going to blog about my journey of losing 100lbs and inspire others and let them help hold me accountable. After losing 50lbs I decided I wanted to push myself further and compete.

What did you do to accomplish your goal? (Food/meal plan and exercise specifics) I did lots of research and completely changed my eating habits. I followed a completely clean eating lifestyle, cut out fast food, soda and sugar. I started walking a mile a day and finding kettle bell videos. Now I have hired a competitor coach and I am lifting heavy and do HIIT 6x a week. She also has me on a strict meal plan.

How did you make time for fitness? Because of my schedule, my husband’s schedule and the kids school/sports, it was best for me to get up at 5:30am and work out.

How long did it take you to reach your goal? It took me a little over a year to get to where I am now. I started my journey January 2013. I will compete on November 2, 2014.

Was there a specific person, website, blog that inspired/motivated you and provided you good information for losing weight/getting fit? I followed a few blogs when I first started. But the clean eating guide by Jamie Eason from bodybuilding.com was very helpful and Marianne from myomytv.com is where I got all of my kettle bell workouts. 

Any other information that you think would be beneficial and inspiring to other women. I always stress on my blog that with dedication and consistency anything is possible. I am going from obese to the competition stage and though difficult, it can and will be done. 

You are one hot mama Valerie!  Please feel free to leave her a sweet note in the comments- she deserves some love! 

The Veterans Administration Scandal: Implications for Health Reform and A Call for Clinical Research Into the Reported Death Rate

As the Population Health Blog understands it, dozens of veterans died while waiting for outpatient appointments at the Phoenix Veterans Administration (VA) Hospital.  Approximately 1500 vets were assigned to an "off-the-books" waiting list that made the clinics' official waiting times appear shorter than they really were. Because waiting times are an important feature of health care quality, the VA was probably holding its local administrators responsible for routinely measuring and reporting them up the chain of command.  If reports are true, instead of using their increased budgetary resources to provide more care, the Phoenix bureaucrats allegedly responded by gaming the system.

And the scandal is flourishing.  Investigations suggest other VA hospitals may have also adopted the same wait-list legerdemain.  A senior D.C. official resigned fast-tracked his already scheduled retirement. The VA Inspector General's investigation prejudgment is that none of the deaths can be attributed to delays in care. You can't make this stuff up.

"Good grief!" says the PHB.  Numerous articles like this, this and this had convinced lay writers, impressive policy wonks and countless physicians that this version of government run health care was not only the greatest thing since the invention of Medicare, but a model for U.S. health care reform.

Not any more.

That's why the implications of this extend far beyond a huge stain on the VA's reputation.  Once again, taxpayers are witnessing another failure of big government. While this has nothing to do with Obamacare, voters have another reason to doubt Washington's ability to competently deliver on its health care promises.

In the meantime, the PHB offers the VA plutocrats one approach to figuring out if the waiting lists were associated with higher death rates.  It's possible, thinks the PHB, to use propensity score matching within the VA's much-admired electronic health record system to retrospectively create a cohort of patients that were similar in every way except for being on the wait list.  A similar death rate in that group - demonstrated by unbiased scientists outside the control of the VA - would go a long way toward reassuring all of us that this debacle was limited to customer service.      

Image from Wikipedia

Bikini Contest Prep (8 Weeks Out Recap)

This Saturday will be 7 weeks until my bikini contest.  Seven weeks sounds so much shorter than 8 weeks, less than 2 months away.  I'm getting a little freaked out because, up to now, I'm mostly just thinking day to day with my food and the training, not really focusing on having to get on stage at the end of this all and be judged.  The scariest part of this is the posing that's required at these bikini shows.  It's not traditional flexing, showing of biceps, but there is a certain way of standing and doing some turns to show off your body from every angle.  In the photo below, the girl in the middle is holding the best pose the way she is twisting her torso.

via IFBB News Online

This is a good example of the pose I'm learning.   This woman, Candice Conroy, placed 1st in the Pro Bikini Division at a 2013contest.  She's 5'2- short like me! :)

via IFBB News Online

I have a posing coach and we've worked together twice, 30 minutes each time.  I have two more sessions with her, unless I need more, which I probably will. The first time was basically awful, she said "I couldn't stand properly, couldn't twist, my middle was too thick, I needed to loosen up and get a massage, I should start tanning right away so I didn't look muddy with the fake tanning paint, my shoes were wrong, I wasn't wearing the right booty shorts, blah blah blah."  I was really discouraged and, due to schedule issues, I didn't go back for 3 weeks.  In her defense, she is very passionate about her sport and takes her career very seriously.  She wants the women she works with to be at the top of their game and to feel very confident when they get on stage.  

The second time (last Friday) was much better.  I had my clear 5-inch heels, the proper booty shorts, my waist had decreased, I put on self-tanner and I was able to hold a pose- albeit sweating my arse off and shaking a little.  It's actually really hard to contort your body this way when you're not used to it and just learning.  My coach snapped a pic when she thought I was holding the poses pretty well- you can see by the look on my face I'm just trying not to tip over.  These are just iPhone pics and I tried to spare you an up-close butt shot. ;)  These photos were taken on Friday, May 9, 2014.  Seeing myself from the back really surprised me (obviously, I never see that view) so I'm happy with the progress on my hamstrings and calves (but she pointed out my left hamstring is more developed than my right).  I had almost no leg muscle definition when I started.  Lunges, lunges, and more lunges.  I do them probably 5 days a week.  Walking lunges, in-place lunges, jumping lunges, lunges with weights, lunges without weights, side to side lunges . . . you get the idea. 

And, for comparison, here's where I started in February- the pic on the left below is me after my first week working out and eating better.  This is almost exactly 3 months' difference.  I hope this encourages you with what you can accomplish in a (relatively) short amount of time. 

I'm trying REALLY hard to be perfect with my food, but it's not the way I love to eat.  I want to eat chocolate everyday, just a small piece at least, but I don't.  I fight this daily, especially in the evening.  My protein shake is chocolate, so it'll have to do.  We are down to the nitty gritty, so everything counts.  And I want to finish strong.  I don't know that I'll ever do this again, so I want to do it well the first time!  

My meal plan is the same, except, I'm down from 1/2 cup of rice to 1/3 cup or from 5oz potato to 4oz.  

I can add seasonings like Mrs. Dash and I learned I could put all natural fruit spread on my pancakes (thank God because I pretty much hate them without peanut butter).  My big fail is my coffee creamer.  I admit to still using it a few times a week!  :(  I know I shouldn't, but damn.

Have a great weekend!

Aren't All Physicians Supposed to Be Experts in Clinical Informatics?

It was just a matter time.  "Clinical informatics" has become another medical specialty.

It seems that the clinical informaticians have their own organization (the "American Medical Informatics Association"or "AMIA"), an American Board of Medical Specialties-backed specialty designation, an accredited fellowship process and even a board examination.

And, like many other medical specialties, their experts are projecting a shortage of themselves and are naturally advocating for an expansion of their training programs.

The JAMA paper linked above provides a useful definition of the science:

"... a body of knowledge, methods, and theories that focus on the effective use of information and knowledge to improve the quality, safety, and cost-effectiveness of patient care as well as the health of both individuals and populations."

While the PHB appreciates the evidence-based definition, it can't help but be slightly disappointed at how this has played out. 

Years ago, when the promise of electronic records still exceeded their reality, there was an assumption among many of the PHB physician colleagues that a few strokes of the the electronic record keyboard would generate on-screen data roll ups. Possible examples included the percent of patients with high blood pressure who weren't controlled, the fraction of persons with diabetes who hadn't had basic immunizations or the number of persons with depression who weren't regularly filling their prescriptions. Us docs could use that information to improve quality, reduce care gaps and optimize costs, both at the point of care and for the entire panel.

In other words, the PHB assumed the EHR would enable all of us docs to become clinical informaticians. 

Alas, it was wrong.  To get the information, physicians will be expected to rely on another specialty to make up for the EHR's lingering shortfalls.

Egads.

Google Bus: A Future for Health Care?

The Population Health Blog's travels have included San Francisco. That's where it got to learn about the "Google Bus" imbroglio.  As the PHB understands it, some Silicon Valley companies have arranged for private buses to transport their high-wage techies to and from work.  Long-term city locals, upset at the rising rents of gentrification, see the luxury buses as emblematic of an upstart class of professionals who are "too good" to take public transportation.

"Welcome to the future of health care!" says the PHB.

As public financing with private insurance subsidies (Obamacare) and government insurance (Medicare and Medicaid) expand, public budgets will sooner or later be insufficient to support their good intentions.  Examples outside of healthcare include education (Chicago), national defense (Pentagon) and infrastructure maintenance (bridges).

While it's no expert on public transportation, it believes the system has been generally starved for funds. Unable to adapt to shifting demand with new routes and new buses, the private sector in San Francisco has stepped up with its own solution.

The same could happen with health care.  While we are headed toward a future where everyone has health insurance, similar underfunding (leading to catastrophes like this) could lead to significant service shortfalls.  Persons - with access to the money it takes to pay their own way - will cut their own deals with private-pay providers and high end hospitals.

They'll ride in luxury and the rest of us will resent it.

Jack Bauer and Health Care Reform: A Multiple Choice Test

Business travel kept the Population Health Blog from being able to watch the live broadcast of Fox Network's "24."  Good thing the spouse DVR'ed the show for the PHB's later viewing pleasure. 

We turned it into a date night.

While it was inspired by the derring-do of super-spy Jack Bauer, the PHB couldn't help itself, and combined some of lessons of 24's TV drama to the conundrum of health care reform.  That's why it concocted this multiple-choice test that simultaneously challenges readers' knowledge of 24's opening episode and Obamacare:

1) After being "off the grid" for four years. Jack reemerges in London, only to be taken into custody by the United States.  Jack is captured because (chose the best answer)......

a) that was his intent all along,
b) his EHR-enabled Google glasses decision support suggested that was the best course of action,
c) his handgun accidentally discharged and traumatically amputated the great toe on his right foot.

2) The U.S. President, who is visiting London, is apparently suffering from a progressive dementing illness.  Viewers know this because (chose the best answer)......

a) he got mixed up over the difference between Ted and Franklin Roosevelt,
b) he believes that the U.S. would be better off with a "single payer" health care system,
c) he believes past-President Obama's malpractice reforms will eventually have an impact.

3) Chloe O'Brian has gone from employed, blond and naïve to unemployed, goth and tattooed. That's because (chose the best answer)......

a) she's gone renegade,
b) if her income were higher, she wouldn't qualify for health insurance premium subsidies,
c) staring at 5 computer monitors simultaneously for so many years has addled her brain.

4) When a Bauer confederate climbed to the top of a van and readied a rocket propelled grenade, the PHB spouse said (chose the best answer)......

a) "Watch this!"
b) "I can't wait until the Blacklist comes on."
c) "His noble visage reminds me of my husband!"

5) Evil doers have figured out to remotely hack drones' Hellfire missile systems. They can do this because (chose the best answer)......

a) of an evil intent against the national interests of the United States,
b) they did not rely on the information technology contractors responsible for the healthcare.gov debacle,
c) that's a risk of handhelds when they're not put on airplane mode prior to take-off.

   

Request for Expressions of Interest: Short term WHO consultancy

Short term consultancy to develop guidance and training materials on addressing health in environmental impact assessments - with a specific application on mining projects

World Health Organization, Geneva, Switzerland 

WHO is implementing a project to develop global guidance on ensuring adequate coverage of health issues as part of environmental impact assessment s (EIA) undertaken on mining projects.

Provisions related to the coverage of human health issues are included within environmental assessment regulations in many countries. In practice, however, coverage of health within EIA is often limited and predominantly only addresses physical environmental considerations (e.g. air, water soil and pollution/emissions related issues). Other factors that influence health, for example related to the social and human environment, are not often included or are considered separately as part of other types of assessments. The resulting picture of health that emerges can therefore be incomplete.

The overall aim of the WHO initiative is to enhance coverage of health in environmental impact assessment, in particular through the development of WHO guidance materials on health in EIA and through the development of training materials for environmental assessment regulators and their health sector counterparts.

WHO seeks an independent consultant(s) to support the above.

The Scope of Work for this consultancy consists of the following tasks:

1. Conduct a literature review of existing materials (including training materials) on health in environmental impact assessment. The primary focus will be on project level application of health in EIA and on the analysis of the extent to which health issues (and health determinants) are covered in current EIA practice. Key enabling factors and barriers influencing coverage of health in EIA should also be considered. To the extent possible, this literature review should take stock of publications available in multiple languages and reflective of experiences/practices in different regions around the world.

2. Develop three (3) guidance notes on health in EIA. These guidance notes should be formulated on the basis of the findings of the above literature review, and on the expertise and experience of the consultant. One of the guidance notes should be oriented towards environmental and health impact assessment regulators - i.e. those responsible for quality control of impact assessments undertaken; one should be orientated towards impact assessment practitioners; and one should be orientated towards project proponents - or entities that would normally commission an impact assessment study.

3. Develop training materials on health in EIA, based on the above guidance notes and on the findings of the literature review. These training materials should take the form of a 3 day course for environmental and health impact assessment regulatory authorities and should address issues related to the quality of coverage of health issues (i.e. what adequate health impact assessments should look like), as well as process related considerations (i.e. how and at what points in the EIA process health issues should be considered). Guidance on evaluation of core competencies of impact assessment practitioners should also be included. 

4. Delivery of the training materials/course in a low to middle income country host to large scale mining activities. Case examples used as pilot training should be based on actual examples from the pilot country. (A national consultant will be engaged to assist with the adaptation of both the guidance notes and training materials, including oversight of translation activities).

5. Updating of the training materials based on feedback from the course participants. 

6. Development of a case study based on the pilot - i.e. documenting lessons learned and
insights from the country experience.

Expected deliverables include: 

• Report detailing results of the initial literature review.
• Guidance notes on health in EIA: one for regulators, one for practitioners, and one for project proponents.
• Training materials on health in EIA, which should include presentations, participant materials, training/instructor materials, and case examples for use in practical exercises.
• Case study of the experience and lessons learned from the pilot. 

The World Health Organization Headquarters Offices in Geneva now invites eligible individuals firms/to indicate their interest in undertaking this work. Interested parties must provide information indicating that they are qualified to perform the above tasks: curriculum vitae, description of similar assignments, experience in similar conditions, examples of relevant reports or publications, etc. The consultant(s) will be selected through a competitive process in accordance with WHO's operating policies and procedures on procurement of services.

The expected start date of this consultancy is 01 June 2014 (or as soon as reasonably possible after that). The training activities are expected to be piloted in Q3 of 2014.

The consultancy will largely be home-based, apart from travel required to deliver the pilot training course.

The consultant will be remunerated at a daily rate that is commensurate with his/her experience and based on the UN common salary scale.

Qualifications and Experiences required: 

• Advanced university degree in public health or a related field. 
• At least 7 (seven) years of international experience working on public health and 
• development issues; 
• Demonstrated experience with the conduct of HIAs and/or integrated EIAs on mining 
• projects; 
• Experienced trainer and facilitator with demonstrated experience in designing and 
• delivering training courses for audience not specialized in public health; 
• Excellent analytical, written and verbal communication skills in English are required; 
• Excellent interpersonal skills 

Expressions of interest must be received no later than 16:00 o'clock on Monday 19 May 2014. 
Please include copies of your CV as well as a description of the kinds of issues you would 
consider as part of this work (i.e. what framing you would take to address health in EIA). The 
expressions of interest are to be delivered electronically to Ms Sophie Schmitt at the following 
email address: schmitts@who.int.

[Via Michaela Pfeiffer, WHO]

Bikini Contest Prep // 8 Weeks Out // Sample LEG Workout

Hi friends! Thank you so much for following along on this fitness journey of mine.  This Saturday marks 8 weeks out from the bikini competition.  I guess this is where the rubber meets the road so to speak because I have more tweaks to my training and diet.  I weighed in today (May 8, 2014) at 108 pounds and 19% body fat.  We will be measuring every 2 weeks. 

Back on April 1, he measured me at 25.5%, so I've lost about 6% body fat in 6 weeks.  I was also 113 pounds, so I'm down 5, but I've gained muscle I'm sure.  I'm aiming to get to about 10% body fat, so my trainer said he wants to modify my diet.  Well, it's already so strict, I didn't want him to cut anything, so I had to fess up that I'm still adding a small amount of peanut butter to my pancakes (and sometimes I eat those twice a day) and I sometimes only get 4 of my 5 meals in.  He was very stern about "peanut butter is not on the meal plan" and explained that everything I put in my body counts and makes a difference. Also, getting in those 5 meals is crucial because eating so often is revving up my metabolism and skipping a meal (for me it's usually the last one) causes my body to store more fat instead of burning it. 

Here's a reminder of the MEAL PLAN I'm on.

For me, I've been eating:

7:30 - 8:00 a.m.  1/2 cup ground oats, dash of cinnamon, 3/4 cup All Whites, 1 real egg white, splash of water (less than 1/4 cup) and make it into a pancake.  I spray the pan with spray coconut oil.

11:00 a.m.  5 oz. chicken (I buy frozen chicken breast and microwave them on the defrost setting- this makes them juicy and not overcooked), 1/2 cup brown rice, 1 cup broccoli or green beans

3:00 p.m.  5 oz. chicken, 1/2 cup brown rice, 1 cup broccoli or green beans

6:00 p.m.  5 oz. fish (I buy frozen Mahi Mahi and cook it in the skillet), 1/2 cup brown rice, 1 cup broccoli or green beans

9:00 p.m.  protein shake

It's this last shake that I need to get in.  I have had cheerios (oops!) a few times or my pancake with peanut butter, but no more.  Eating this way honestly hasn't been that bad (or as bad as I thought it would be).  Once I figured out how to cook my chicken so it wasn't bone dry, I enjoyed it more. Also, I know I COULD eat whatever I want really- I'm CHOOSING to do this because I want to see the results.  I LOVE the impact this eating/exercise plan is having on my body.  I'm almost 40 and getting into the best shape ever.  

:: WORKOUTS :: 

We are upping my cardio to 45 minutes 5 days a week.  He actually recommended 5-6 days, but dang!  AND finally, we are training together about 4-5 days a week- up from 3.  I'm doing the cardio right before or after our workouts just to get it over with for the day.  

This has me pooped people!  I definitely need my sleep or I'm so out of steam in the mooring for the workouts.  These exercises we do are killer.  My heart rate is up the whole time, with maybe a minute rest after 3 sets.  

To give you an example, we worked LEGS today.  I did:

Inner leg machine (20 reps x 3- 40 pounds?)

Outer leg machine (20 reps x 3- 40 pounds?)  Not too bad, weight isn't that heavy.  Maybe I should up it next time?

via

Walking lunges (probably 200- I lunge up and down the gym 4 times.  No weight.)

Tire Tipping (outside- down a long row- up and back- 3x) That tire is f*&king heavy.  And dirty.  My hands were gross. 

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Sled Pushes (outside- down a long row- 3x pushing, then pulling it backwards 3x- not sure the weight, definitely not as much as pictured below- maybe 25 pounds??) Feeling like a sweaty beast.  A strong sweaty beast.

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Step-up on high step (15 on each leg x3)

Step-up on even higher step (12 on each leg x 3)  OMG- I'm short remember??!! 

Bike for one minute (x3)  Never has one minute felt longer.

Kettle Bell Plie Squats (30lb) my feet were each on a step, and I had to touch the kettle bell to the ground (15 reps, 3x) Dang these hurt, I have to stop mid-way through for a quick second.  Legs on fire.

Bike for one minute (x3) Are we done yet?!?! 

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Then off to 45 minutes on the treadmill.  I alternated walking briskly at 3.8 no incline and incline at 15% at 2.5. 15% is as high as their treadmills go. Sweaty.  Sweaty.  Sweaty.  And hungry.  The end.  Until tomorrow.