Podcast appearances and mentions of beth israel deaconess

Send us a textInteroperability has long been a buzzword in healthcare In an ideal world, our healthcare system would exchange timely, high-quality data to empower patients, improve clinical quality, and keep costs under control. How close are we to making this a reality?In this episode of the HealthBiz Podcast, host David E Williams talks with Dr. Donald Rucker, Chief Strategy Officer at 1upHealth, about how their health data management platform is transforming the way healthcare organizations access, share, and leverage patient data to improve outcomes, enhance efficiency, and drive more personalized care.TOPICS(0:25) Introduction(0:52) How Dr. Donald Rucker Got Into Healthcare(2:54) Rucker's Educational Path and Career(11:14) What Does 1upHealth Do?(21:13) Why Are CMS APIs So Important?(25:15) How Do APIs Affect Prior Authorization?(31:37) Book Recommendations from Dr. Donald Rucker

This episode, recorded live at the Becker's Healthcare 12th Annual CEO + CFO Roundtable features Ruben Azocar, VP for Perioperative Services at Beth Israel Deaconess Medical Center. Here, he shares his perspectives on addressing cybersecurity risks, leveraging artificial intelligence for operational efficiency, and tackling financial challenges in healthcare. He discusses strategies for improving patient care while managing costs, and how AI can support the revenue cycle and enhance the use of operating rooms.In collaboration with R1.

Audible Bleeding editor Wen (@WenKawaji) is joined by 3rd year medical student Nishi (@Nishi_Vootukuru), JVS editor Dr. Forbes (@TL_Forbes), and JVS social media liaison Dr. Haurani to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Marc Schermerhorn, Dr. Andrew Sanders, Dr. Mitchell Cox and Dr. Junji Tsukagoshi, the authors of the following papers.    Articles:   Ten Years of Physician Modified Endografts Peri-operative and intermediate outcomes of patients with pulmonary embolism undergoing catheter-directed thrombolysis vs. percutaneous mechanical thrombectomy    Show Guests  Dr. Marc Schermerhorn: Chief of vascular and endovascular surgery at Beth Israel Deaconess and professor of surgery, Harvard Medical School  Dr. Andrew Sanders: PGY4 general surgery resident at Beth Israel Deaconess  Dr. Mitchell Cox: Division chief of vascular surgery and endovascular therapy, program director of the vascular surgery residency program at the University of Texas Medical Branch.  Dr. Junji Tsukagoshi: Fourth year vascular surgery resident at the University of Texas Medical Branch in Galveston Texas.  Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

This segment of Cancer Registry World highlights the vital role that regional cancer registrar organizations play in supporting the oncology data specialist community. Sheila Malacaria, ODS-C, Manager of the Cancer Registry at Beth Israel Deaconess Medical Center in Boston, and Ren Garcia, ODS-C, Oncology Data Manager and Registry Quality Analyst at AMN Healthcare in Portland, ME, both serve in leadership roles within the Cancer Registrars Association of New England (CRANE). They share insights on how regional associations fulfill the educational and networking needs of ODS professionals, fostering growth and collaboration across the field.

Audible Bleeding editor Wen (@WenKawaji) is joined by 4th-year general surgery resident Sasank Kalipatnapu (@ksasank) from UMass Chan Medical School, JVS editor Dr. Forbes (@TL_Forbes), JVS-VS associate editor Dr. John Curci (@CurciAAA) to discuss some of our favorite articles in the JVS family of journals. This episode hosts Dr. Mota, Dr. Liang and Dr. Weinkauf, authors of the following papers.   Articles: The impact of travel distance in patient outcomes following revascularization for chronic limb-threatening ischemia Serum detection of blood brain barrier injury in subjects with a history of stroke and transient ischemic attack  Show Guests: Dr. Lucas Mota- third-year general surgery resident at the Beth Israel Deaconess Medical Center Dr. Patrick Liang- assistant professor at Harvard medical school and a practicing vascular surgeon at the Beth Israel Deaconess medical center.  Dr. Weinkauf - assistant professor with the Department of Surgery Division of Vascular and Endovascular Surgery at the University of Arizona College of Medicine  Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and provide us with your feedback with our listener survey.

El renombrado cosmólogo Bernard Carr explora el misterio de los universos paralelos con Sadhguru en una discusión facilitada por el Dr. Bala Subramaniam, Profesor de Anestesiología en la Escuela de Medicina de Harvard. El evento fue organizado por el Centro Sadhguru para un Planeta Consciente en el Centro Médico Beth Israel Deaconess. Learn more about your ad choices. Visit megaphone.fm/adchoices

New treatments and managing side effects are key challenges in kidney cancer care. In our latest episode of The PQI Podcast, we team up with the Kidney Cancer Association, Emily Wang, PharmD, BCOP, from MD Anderson, and Julia Stevens, PharmD, BCOP, from Beth Israel Deaconess, to share valuable insights into the newest advancements in kidney cancer therapies and practical strategies for managing side effects from TKI and IO treatments. Listen now to gain valuable knowledge that can transform your patient care approach.Learn more about the Kidney Cancer Association here. 

We continue our Year of the Zebra focus on rare diseases today by exploring the ability of AI technology to aid in the diagnosis of rare and other conditions by analyzing the voice and speech of the patient. This approach is promising enough that the National Institutes of Health has invested in research projects to test its effectiveness, and the private sector is pursuing it as well, including the company Canary Speech whose technology can be trained to detect conditions that are traditionally difficult to identify, or those where early identification is crucial to treatment. “With just seconds of conversational speech, we can screen for multiple behavioral and cognitive conditions,” says Caitlyn Brooksby, Canary's vice president of Marketing and Strategic Partnership. One prime example she offers is a study on Huntington's disease done in collaboration with Beth Israel Deaconess Medical Center in which more than a thousand features of speech were identified differentiating healthy patients from those with the disease. “Every ten seconds, we're looking at millions of data points, but we don't look at the words you say. We're looking at biomarkers within speech such as duration per word, word-per-second, bandwidth and contrast. It's really incredible what we can gather from speech alone,” she explains. Canary is in the second iteration of its Huntington's model which is showing accuracy rates of 90% and above, and it recently added mild cognitive impairment, Alzheimer's, and Parkinson's disease to its offerings. Join host Lindsey Smith on this episode of Raise the Line to learn more about this promising approach to diagnosis.Mentioned in this episode:Canary Speech 

Dean's Chat hosts, Dr. Jensen, and Dr. Richey, interview a tremendous leader in podiatric medicine and surgery, Dr. Thanh Dinh. Dr. Dinh is the Residency Director for the Beth Israel Deaconess Medical Center Podiatric Surgical Residency. We discuss the residency program, teaching styles, giving valuable feedback to residents, and the clerkship experience. She is an Assistant Professor in the Department of Surgery, at Harvard University. She has been involved extensively in research including NIH-funded research and industry-funded clinical trials. As President of the American College of Foot and Ankle Surgeons in 2020-2021, Dr. Dinh provided valuable leadership and service to our profession during the COVID-19 epidemic. Dr. Dinh shares insights about her impressive career as an assistant professor at Harvard Medical School and residency director at Beth Israel Deaconess Medical Center. The conversation delves into the residency program at Beth Israel Deaconess, highlighting Tan's passion for training future podiatrists. Tune in for an engaging discussion with these podiatric experts! Dr. Jensen, Dr. Richey, and Dr. Dinh discuss how residency programs are essential in shaping the future of healthcare by training well-rounded physicians. Dr. Thanh Dinh emphasized the critical role of residency programs in training podiatric surgeons to excel not only in surgical skills but also in demonstrating care, talent, and a warm bedside manner. She stressed the importance of training physicians who are responsible members of the healthcare community, and capable of providing compassionate care to their patients. Dr. Dinh's approach to residency training focused on fostering curiosity and a willingness to question the status quo among residents. She encouraged residents to ask "why" and understand the reasoning behind their actions, rather than blindly following tradition. By creating an environment where residents are empowered to question and seek understanding, Dr. Dinh aimed to cultivate a sense of identity and purpose within the healthcare profession. Moreover, Dr. Dinh highlighted the significance of providing feedback to residents in a constructive and supportive manner. She emphasized feedback as a valuable tool that can help residents grow and enhance their skills. By promoting reflection and open communication, residency programs can assist residents in developing not only their clinical competencies but also their emotional intelligence and patient-centered care. Overall, the episode underscores the importance of residency programs in shaping well-rounded physicians who not only possess technical expertise but also demonstrate empathy, communication skills, and a commitment to patient care. By focusing on training physicians who are caring, talented, and have a warm bedside manner, residency programs can contribute to the development of healthcare professionals who are not only skilled clinicians but also compassionate caregivers. A lifelong learner, she also enjoys time with her family and is an avid runner. Join us for a fun discussion with Dr. Thanh Dinh! Enjoy! https://explorepodmed.org/ Dean's Chat Website Dean's Chat Episodes Dean's Chat Blog Why Podiatric Medicine?  Become a Podiatric Physician https://lelandjaffedpm.com https://higherlearninghub.com  

¿Sabían que de acuerdo con el Centro Médico Beth Israel Deaconess en Boston, a partir de los 30 años perdemos el 8% de la masa muscular y lo reemplazamos con grasa, incluso si somos personas activas? Nicolás Mier y Terán va a explicarnos por qué con los años nos cuesta más trabajo perder peso y cómo podemos revertir este efecto de manera saludable. Hosted on Acast. See acast.com/privacy for more information.

¿Sabían que de acuerdo con el Centro Médico Beth Israel Deaconess en Boston, a partir de los 30 años perdemos el 8% de la masa muscular y lo reemplazamos con grasa, incluso si somos personas activas? Nicolás Mier y Terán va a explicarnos por qué con los años nos cuesta más trabajo perder peso y cómo podemos revertir este efecto de manera saludable. Hosted on Acast. See acast.com/privacy for more information.

CardioNerds join Dr. Inbar Raber and Dr. Susan Mcilvaine from the Beth Israel Deaconess Medical Center for a Fenway game. They discuss the following case: A 72-year-old man presents with two weeks of progressive dyspnea, orthopnea, nausea, vomiting, diarrhea, and right upper quadrant pain. He has a history of essential thrombocytosis, Barrett's esophagus, basal cell skin cancer, and hypertension treated with hydralazine. He is found to have bilateral pleural effusions and a pericardial effusion. He undergoes a work-up, including pericardial cytology, which is negative, and blood tests reveal a positive ANA and positive anti-histone antibody. He is diagnosed with drug-induced lupus due to hydralazine and starts treatment with intravenous steroids, resulting in an improvement in his symptoms. Expert commentary is provided by UT Southwestern internal medicine residency program director Dr. Salahuddin (“Dino”) Kazi. US Cardiology Review is now the official journal of CardioNerds! Submit your manuscript here. CardioNerds Case Reports PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Case Media Pearls - A Drug's Adverse Effect Unleashes the Wolf The differential diagnosis for pericardial effusion includes metabolic, malignant, medication-induced, traumatic, rheumatologic, and infectious etiologies. While pericardial cytology can aid in securing a diagnosis of cancer in patients with malignant pericardial effusions, the sensitivity of the test is limited at around 50%.  Common symptoms of drug-induced lupus include fever, arthralgias, myalgias, rash, and/or serositis. Anti-histone antibodies are typically present in drug-induced lupus, while anti-dsDNA antibodies are typically absent (unlike in systemic lupus erythematosus, SLE). Hydralazine-induced lupus has a prevalence of 5-10%, with a higher risk for patients on higher doses or longer durations of drug exposure. Onset is usually months to years after drug initiation. Show Notes - A Drug's Adverse Effect Unleashes the Wolf There is a broad differential diagnosis for pericardial effusion which includes metabolic, malignant, medication-induced, traumatic, rheumatologic, and infectious etiologies. Metabolic etiologies include renal failure and thyroid disease. Certain malignancies are more likely to cause pericardial effusions, including lung cancer, lymphoma, breast cancer, sarcoma, and melanoma. Radiation therapy to treat chest malignancies can also result in a pericardial effusion. Medications can cause pericardial effusion, including immune checkpoint inhibitors, which can cause myocarditis or pericarditis, and medications associated with drug-induced lupus, such as procainamide, hydralazine, phenytoin, minoxidil, or isoniazid. Trauma can cause pericardial effusions, including blunt chest trauma, cardiac surgery, or cardiac catheterization. Rheumatologic etiologies include lupus, rheumatoid arthritis, systemic sclerosis, sarcoid, and vasculitis. Many different types of infections can cause pericardial effusions, including viruses (e.g., coxsackievirus, echovirus, adenovirus, human immunodeficiency virus, and influenza), bacteria (TB, staphylococcus, streptococcus, and pneumococcus), and fungi. Other must-not-miss etiologies include emergencies like type A aortic dissection and myocardial infarction. In a retrospective study of all patients who presented with a hemodynamically significant pericardial effusion and underwent pericardiocentesis, 33% of patients were found to have an underlying malignancy(Ben-Horin et al). Bloody effusion and frank tamponade were significantly more common among patients with malignant effusion, but the overlap was significant, and no epidemiologic or clinical parameter was found useful to differentiate between cancerous and noncancerous effus...

Dr. Steven J. Spear (DBA MS MS)Principal, HVE LLCSr. Lecturer, MIT Sloan SchoolSr. Fellow, Institute for Healthcare ImprovementCreator, See to Solve Gemba and Real Time Alert SystemsSSpear@MIT.edu www.SeeToSolve.com Steve@HVELLC.comKnowing how to get smarter about what you do and better at doing it, faster than anyone else, is critical, a bona fide source of sustainable competitive advantage.How so? All organizations share a challenge. They're trying to coordinate people—sometimes a few, sometimes many thousands—towards shared purpose, somewhere on the spectrum from upstream conceptualization and discovery, through development, design, and ultimately delivery. The problem is, particularly at the startof any undertaking, no one really knows what to do, how to do it, nor can they do it well. All that has to be invented, created, discovered…figured out. So, those who solve problems faster, win more. After all, if your team and mine chase similar goals (or we face off as adversaries), you succeed (or win) because you come to your moments of test better prepared than I do. Since knowhow and skills are not innate, you won because you solved your problems, better and faster than I didmine, gaining edges in relevance, reliability, resilience, and agility.Spear's work focuses on the theme of leading complex collaborative situations, imbuing them with powerful problem solving dynamics. The High Velocity Edge earned the Crosby Medal from ASQ. “Fixing Healthcare from the Inside” won a Harvard Business Review McKinsey Award, and five of Spear's articles won Shingo Prizes. “Decoding the DNA of the Toyota Production System” is a leading HBR reprint and part of the “lean” canon. He's written for medical professionals and educators in Annals of Internal Medicine, Academic Medicine, and Health Services Research, for public school superintendents in Academic Administrator, and for the general public in the New York Times, the Boston Globe, Fortune, and USA Today. High velocity learning concepts have been tested in practice, helping building internal capability for accelerated improvement and innovation at Alcoa—which generated recurring savings in the $100s of millions, Beth Israel Deaconess, a pharma company—with compressions by half in a key drug development phase, Intel, Intuit, Pittsburgh hospitals, Memorial Sloan Kettering, Mass General, Novartis, Pratt and Whitney—which won the F-35 engine contract with its pilot, DTE Energy, US Synthetic, and the US Army's Rapid Equipping Force. The Chief of Naval Operations made high velocity learning a service wide initiative, and Spear was one of a few outside advisors to the Navy's internal review of 2017's Pacific collisions. He was also an advisor to Newport News Shipbuilding bout introducing innovative systems on the Gerald Ford, the first in a new generation of aircraft carriers. The See to Solve suite of apps has been developed to support introducing and sustaining high velocity learning behaviors.At MIT, Spear teaches Leaders for Global Operations and Executive Education students, has advised dozens of theses, and is principal investigator for research titled “Making Critical Decisions with Hostile Data.” Spear's work history includes Prudential-Bache Capital Funding, the US Congress Office of Technology Assessment, the LongTerm Credit Bank of Japan, and the University of Tokyo. His doctorate is from Harvard, his masters in mechanicalengineering and in management are from MIT, and he majored in economics, at Princeton, to earn his bachelors.Spear lives in Brookline with his wife Miriam, an architect, and their three children, where he is on the board of the Maimonides School.Link to claim CME credit:

Alexa B. Kimball, President & CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center joins the podcast to discuss her background, top priorities right now, how her organization will evolve over the next couple years, and one change that she or her team has made that she is proud of.

Alexa B. Kimball, President & CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center joins the podcast to discuss her background, top priorities right now, how her organization will evolve over the next couple years, and one change that she or her team has made that she is proud of.

This episode features Molly Gamble, Vice President of Editorial at Becker's Healthcare. Here, she discusses the possibility of Amazon tying healthcare to Prime, Prenuvo full-body MRI scans & their marketing strategy, and Dana-Farber picking Beth Israel Deaconess over Brigham for their new cancer hospital.

Sixty-seven thousand Kaiser Permanente workers vote to authorize a strike. Dana-Farber and Beth Israel Deaconess partner on a new cancer center. And, Oregon approves a plan to create a new basic health plan for residents who earn too much to qualify for Medicaid. That's coming up on today's episode of Gist Healthcare Daily. Hosted on Acast. See acast.com/privacy for more information.

“What's really exciting and scary in medical education right now is we're seeing large language models enter the scene,” says today's Raise the Line guest Dr. Adam Rodman, who is well-placed to make such an assessment. As co-director of the Innovations in Media and Education Delivery Initiative (iMED) at the Beth Israel Deaconess Medical Center, Rodman is witnessing, and influencing, how new technologies are shaping both medical education and the future of healthcare.  In his view, AI can't replace a doctor right now, but it can make remarkable insights into how humans think. “We need to start to grapple with what it means when a lot of these cognitive processes that medical education is designed to train for get offloaded to a machine,” he tells host Shiv Gaglani. He summarized his thoughts on AI, with co-author Dr. Avraham Cooper, in a piece for the August issue of the New England Journal of Medicineentitled “AI and Medical Education: A 21st-Century Pandora's Box” and invokes another concept rooted in ancient Greece as he describes AI as a ‘pharmakon.' “There really is a way these technologies could dramatically improve what it means to be a patient -- and hopefully what it means to be a physician -- but the same technologies could be used to make things worse.” The ancient references are not surprising coming from Rodman, a medical historian who enjoys exploring the roots and evolution of the field on his long-running podcast Bedside Rounds. Don't miss this richly informed conversation on how humans perform when interacting with AI, the advent of virtual tutors, and how AI might be used to improve student assessments and enhance the doctor-patient relationship. 

Transcript Eric Topol (00:00):This is a real great opportunity to speak to one of the most impressive medical informaticists and leaders in AI in the United States and worldwide. Dr. John Halamka, just by way of background, John, his baccalaureate in Stanford was at U C S F/Berkeley for combined MD PhD trained in emergency medicine at U C L A. He went on to Harvard where he, for 20 years was the Chief Information Officer at Beth Israel Deaconess. And then in 2020 he joined Mayo Clinic to head its platform to help transform Mayo Clinic to be the global leader in digital healthcare. So welcome, John. It's so great to have you. And by the way, I want to mention your recent book came out in April, one of many books you've written, redefining the Boundaries of Medicine, the High Tech High Touch Path into the Future.John Halamka (01:00):Well, a thrilled to be with you today, and you and I need to spend more time together very clearly.Eric Topol (01:06):Yeah, I really think so. Because this is the first time we've had a one-on-one conversation. We've been on panels together, but that's not enough. We've got to really do some brainstorming, the two of us. But first I wanted to get into, because you have been on a leading edge of ai and Mayo is doing big things in this space, what are you excited about? Where do you think things are right now?John Halamka (01:35):So you and I have been in academic healthcare for decades, and we know there's some brilliant people, well-meaning people, but sometimes the agility to innovate isn't quite there, whether it's a fear of failure, it's the process of getting things approved. So the question of course is can you build to scale the technology and the processes and change policies so that anyone can do what they want much more rapidly? And so what's been exciting over these last couple of years at Mayo is we started with the data and we know that anything we do, whether it's predictive or regenerative, starts with high quality curated data. And so by de-identifying all the multimodal data of Mayo and then working with other partners around the world to create a distributed federated approach for anyone to train anything, suddenly you're empowering a very large number of innovators. And then you've seen what's happened in society. I mean, culturally, people are starting to say, wow, this ai, it could actually reduce burden, it could democratize access to knowledge. I actually think that yes, there need to be guidelines and guardrails, but on the whole, this could be very good. So here we have a perfect storm, the technology, the policy, the cultural change, and therefore these next couple of years are going to be really productive.Implementing a Mayo Randomized AI TrialEric Topol (02:59):Well, and especially at Mayo, the reason I say that is not only do they recruit you, having had a couple of decades of experience in a Harvard program, but Mayo's depth of patient care is extraordinary. And so that gets me to, for example, you did a randomized trial at Mayo Clinic, which there aren't that many of by the way in AI where you gave E C G reading power of AI to half the primary care doctors and the other half you didn't for determining whether the patients had poor cardiac function that is low ejection fraction. And now as I understand it, having done that randomized trial published it, you've implemented that throughout the Mayo Clinic system as far as this AI ECG support. Is that true?John Halamka (03:56):Well, right, and let me just give you a personal example that shows you how it's used. So I have an SVT [supraventricular tachycardia] , and that means at times my resting heart rate of 55 goes to one 70. It's uncomfortable. It's not life-threatening. I was really concerned, oh, may I have underlying cardiomyopathy, valvular disease, coronary artery disease. So Paul Friedman and Peter Newsworthy said, Hey, we're going to take a six lead ECG wearable, send it to your home and just record a bunch of data and your activities of daily living. And then we buy 5G cell phone. We'll be collecting those six leads and we'll run it through all of our various validated AI systems. And then we'll tell you based on what the AI suggests, whether you're at high risk or not for various disease states. So it says your ejection fraction 70%. Oh, good. Don't have to worry about that. Your likelihood of developing AFib 3% cardiomyopathy, 2% valvular disease, 1%. So bottom line is without even going to a bricks and mortar facility here, I have these validated algorithms, at least doing a screen to see where maybe I should get additional evaluation and not.Eric Topol (05:12):Yeah, well see what you're bringing up is a whole other dimension. So on the one hand that what we talked about was you could give the primary care doctors who don't read electrocardiograms very well, you give them supercharged by having a deep learning interpretation set for them. But on the other, now you're bringing up this other patient facing story where you're taking a cardiogram when somebody's perfectly fine. But from that, from having deep learning of cardiograms, millions of cardiograms, you're telling what their risks are that they could develop things like atrial fibrillation. So this is starting to span the gamut of what the phase that we went through or still going through, which is taking medical images, whether it's a cardiogram or a scan of some sort, and seeing things with machines that humanize really can't detect or perceive. So yeah, we're just starting to get out of the block here, John. And you've already brought up a couple of major applications that we were not even potentially used three, four or five years ago that Mayo Clinics leading the charge, right?The Power of Machine EyesJohn Halamka (06:26):Well, yeah, and let me just give you two quick other examples of these are in studies now, right? So they're not ready for active patient use. The animate GI product does an overread of endoscopy. And what we're finding is that the expert human, I mean anywhere in the world, expert humans miss about 15% of small polyps. They're just hard to see. Prep may not be perfect, et cetera. The machine misses about 3%. So that's to say a human augmented with overread is five times better than a human alone pancreatic cancer, my father-in-law died about 11 years ago of stage four pancreatic cancer. So this is something that I'm very sensitive about, very often diagnosed late, and you can't do much. What we've been able to see is looking at pancreatic cancer, early films that were taken, abdominal CT scans and these sorts of things, algorithms can detect pancreatic cancer  two years before it is manifested clinically. And so here's the ethical question I'll pose to you. I know you think about a lot of this Scripps Mayo, UCSF, Stanford, we probably have thousands and thousands of abdominal CTs that were read normal. Is it an ethical imperative as these things go through clinical trials and are validated and FDA approved to rerun algorithms on previous patients to diagnose disease we didn't see?Eric Topol (08:03):Well, that is a really big important question because basically we're relieving all this stuff on the table that doesn't get diagnosed, can't be predicted because we're not even looking for it. And now whether it's retina, that is a gateway to so many systems of the body, or as you're mentioning various scans like an abdominal CT and many others that like mammography for heart disease risk and all sorts of things that weren't even contemplated that machine eyes can do. So it's really pretty striking and upending cancer diagnosis, being able to understand the risk of any individual for particular types of cancer so that you can catch it at the earliest possible time when it's microscopic before it spreads. This, of course, is a cardinal objective. People don't die of cancer per se. They die of its metastasis, of course, for the most part. So that gets me now to the next phase of ai because what we've been talking for mostly so far has been what has been brewing culminating for the last five years, which is medical images and what, there's so many things we can glean from them that humans can't including expert humans in whatever discipline of medicine.Multimodal AI and Social Determinants of Health(09:19):But the next phase, which you are starting to get at is the multimodal phase where you're not just taking the images, you're taking the medical records, the EHRs, you're getting the genomics, the gut microbiome, the sensors. You mentioned one, an ECGs, a cardiogram sensor, but other sensors like on the wrist, you're getting the environmental things like air pollution, air quality and various things. You're getting the whole ball of wax any given individual. Now, that's kind of where we're headed. Are you doing multimodal ai? Have you already embarked in that new path? Now that we have these large language modelsJohn Halamka (10:02):And we have, and so like anything we do in healthcare innovation, you need a Pareto diagram to say, what do you start with and where do you go? So in 2020, we started with all of the structured data problems, meds, allergies, labs. Then we went to the unstructured data, billions of notes, op reports, H and Ps, and then we moved to telemetry, and then we moved to CT, MRI, PET. Then we move to radiation oncology and looking at all the auto contouring profiles used in linear accelerators and then to omic, and now we're moving to an inferred social determinants of health. And let me explain that for a minute.(10:45):Exposome, as you point out, is really critical. Now, do you know if you live in a Superfund site area, do you know what risks you might have from the PM 2.5 particulates that are blowing through San Diego? Probably you don't. So you're not going to self-report this stuff. And so we have created something called the house Index where we've taken every address in the United States, and based on the latitude and longitude of where you live, we have mapped air, water, land, pollution, access to primary care, crime, education, grocery stores, stores, and therefore we can infer about 40 different things about your expose em just from where you live. And that's a mode. And then as you say, now, starting to gather remote patient monitoring. We have this acute advanced care in the home program where we're taking serious and complex illness, caring for the patient in the home, starting to instrument homes and gather a lot more telemetry. All of that multimodal data is now available to any one of the 76,000 employees of Mayo and our partners for use in algorithm development.Eric Topol (11:58):Yeah, no, that's extraordinary. And I also would say the social determinants of health, which you've really gotten into as its importance. There are so many papers now over the last several years that have emphasized that your zip code is one of the most important things of your health. And it's not even just a zip code. It's your neighborhood within that zip code for the reasons that you've mentioned. And inferring that and imputing that with other sources of data is vital. Now, this multimodal, you've again anticipated one of my questions, the possibility that we can gut hospitals as we know them today. Yes, preserving the ICUs, the emergency departments, the operating rooms, but those other people that occupy the vast majority of beds in the hospital that are not very sick, critically Ill. Do you think we're going to move as you're innovating at Mayo whereby we'll be able to keep those people at home for the most part in the years ahead? I mean, this isn't going to happen overnight, but do you think that's where we're headed?The Hospital-at-HomeJohn Halamka (13:08):So to date, Mayo and its partners have discharged about 23,000 patients from their homes. And as you can guess, we have done clinical trials and deep dive studies on every one of the patient's journeys. And what have we seen across 23,000 patients? Well, so generally, about 30% of patients that present for acute care to an emergency department come in by ambulance are appropriate for care in non-traditional settings. I mean, I think you would agree, somebody with episodic ventricular tachycardia, you're probably not going to put in a home setting, but somebody with congestive heart failure, COPD, pneumonia, I mean, these are things that, as you say, if they're going to get sicker, it will be over hours, not minutes. And therefore you can adjust in these molar than 20,000 patients. What we've seen is the outcomes are the same, the quality is the same safety, the same patient satisfaction. You get net promoter scores in the mid-nineties. You find me a hospital with a net promoter score in the mid nineties. You're eating your own food, slipping your own bed. Oh, your granddaughter's coming at 2:00 AM on a Sunday, whatever. And then ask yourself this other question, nosocomial infections,Eric Topol (14:31):Right?John Halamka (14:31):How many methicillin resistant staph infections do you have in your office? You're like, none, right? So you're infections in fall, so okay, better, stronger, cheaper, faster. And the safety of the quality are that for about 30% of the population should be a standard of care.Eric Topol (14:56):That's really big. So you don't think we have to do randomized trials to prove it?John Halamka (15:01):I mean, we have done enough studies to date, and there are organizations, Kaiser Permanente, Cleveland Clinic, all these folks who are joining us in investigating these areas. And the data is very compelling.Patients Asking Questions to LLMsEric Topol (15:17):Yeah, that's really exciting. And we may be able to jump past having to go through the large trials to prove what you just reviewed. So that's one thing of course that we're looking for in store. Another is the patient doing advanced large language model searches. So as you and everyone knows, we've done Google searches for years about symptoms, and inevitably people come up with hypochondria because they have some horrible disease that they looked up that is not a very good match specific for their condition and their background. But soon already today, we have people going into being creative mode, G P T four and other searches, and they're getting searches about their diagnosis and about what's the best literature and best treatments and expectations. That won't be FDA regulated. We don't have regulation of Google searches. So how do you see the democratization of large language models with patients having conversations with these chatbots?John Halamka (16:32):And of course, you ask a question no one has answered yet, but here are a few threads. So we know the challenge with existent commercial models as they're trained on the public internet. Some are trained on additional literature like PubMed or a mimic dataset, but none are trained on the rich clinical experience of millions and millions of patients. So therefore, they don't have the mastery of the care journey. So question, we are all asking, and again, no one knows. Then you take a GPT, BARD, a MedPaLM and additional pre-training with rich de-identified clinical experience and make it a better model for patients who are going to ask questions. We've got to try and we've got to try within guardrails and guidelines, but we definitely want to explore that. Can you or should you train a foundational model from scratch so that it doesn't have the bias of Reddit and all of the various kinds of chaff you find on the public internet? Could be very expensive, could be very time consuming. Probably society should look at doing it.Eric Topol (17:50):So this is just a review for those who are not up to speed on this, this means setting up a base model, which could be 20 to 30,000 graphic processing units, big expense. We're talking about tens of millions, but to do it right, so it isn't just a specialized fine tuning of a base model for medical purposes, but something that's de novo intended that no one's done yet. Yeah, that's I think a great idea if someone were to go down that path. Now you, early on when we were talking, you mentioned partners, not just other health systems, but one of the important partners you've established that's been out there as Google, which I think set up shop right in Rochester, Minnesota, so it could work closely with you. And obviously they have MedPaLM2, they have BARD, they published a lot in this space. They're obviously competing with Microsoft and others, but seems like it's mainly an arms race between those two and a few others. But how is that relationship going? And you also were very right spot on about the concerns of privacy, federated ai, privacy computing. Can you tell us about Mayo and Google?What is the Collaboration Between Mayo and Google?John Halamka (19:06):Well, absolutely. So Google provides storage, compute, various kinds of tools like their fire engine for moving data between various sources. Google does not have independent access to any of Mayo's data. So this isn't a situation of we have a challenging medical or engineering problem, bring 60 Google engineers to work on it. No, what they mean is they help us create the tooling and the environment so that then those with permission, Mayo employees or Mayo's partners can work through some of these things and build new models, validate models. So Google has been a great enabler on the tool set and building scale. You probably saw that Eric Horvitz gave a recent grand rounds at Stanford where he explained scale makes a difference, and that you start to see these unexpected behaviors, this emerging goodness, when you start dealing with vast amounts of multimodal data, vast amounts of compute. And so working with a cloud provider is going to give you that vast amounts of compute. So again, privacy, absolutely essential, de-identify the data, protect it, control it, but you can't as an institution, get enough computing power locally to develop some of these more.Towards Keyboard Liberation and Machine Chart ReviewEric Topol (20:36):Well, that goes back to the dilemma about building a base model with just the capital costs no less. You can't even get these GPUs scale because their supply and demand mismatch is profound. Well, the other thing, there's two other areas I want to get your impressions about. One of course is the change of interactions with patients. So today, as you well know, having all these years overseeing the informatics, Beth Israel now Mayo, the issue of the keyboard and the interference that it provides, not just as a data clerk burden to clinicians, which is horrible for morale and all the hours even after seeing patients that have to be put into charting through the EHRs and these clunky software systems that we are stuck with, but also the lack of even having face-to-face eye contact with patients in that limited time they have together. Now, there are many of these so-called ambient AI language, natural language processing, using large language models that are of course turning that conversation not just to a remarkable note, but also of course any part of the note, you could go back to the raw conversation. So it has trust embedded as what was really said. And then you have all these downstream functions like prescriptions, follow-up appointments, nudges to the patients about whatever, like their blood pressure or things that were discussed in the visit. You have translation to the patient at their level of education so they can understand the note you have things that we never had before. You have orders for the test or follow up appointment pre-authorization. What about these, John, are these the real deal or are we headed to this in the near term?John Halamka (22:41):So 10 years ago, I said all of these meaningful use criteria, all the keyboarded data entry, structured data and vocabularies. What if you had the doctor and the patient had a conversation and the conversation was the record? That was the legal record. And then AI systems extracted the structured data from the conversation. And there you would have satisfaction by both patient and doctor and a very easy source of truth. Go back to what was said. And of course, 10 years ago everyone said, that'll never happen. That's too far.(23:20):And so I'll give you a case. My mom was diagnosed with a brain abscess about a year ago. She's a cure of the brain abscess. I with ambient listening, had a conversation with my mother and it went something like this. Yes, I started to develop a fever. I said, oh, and you live alone, right? Oh, yes. My husband died 13 years ago. The note comes out, the patient is an 81 year old widow. So we're having a conversation about my father dying and she lives alone. And I didn't use the word widow, she didn't use the word widow. And so what it shows you is these systems can take detailed conversation, turn them into abstract concepts and record them in a way that's summarized and meaningful. Last example I'll give you recently, I did grand rounds at Mayo and I said, here's a challenge for all of us. It's Sunday at three in the morning. Mrs. Smith has just come in. She has a 3000 page chart, 75 hospitalizations and four or visits. Her complaint tonight is, I feel weak,Eric Topol (24:38):Right? That's a classic.John Halamka (24:43):How are you going to approach that? So we have an instance of MedPaLM2 that is containerized. So that I was able to put a prompt in it with some background data without, and it was all de-identified, but it was all very secure. So I put the 3000 pages into this MedPaLM2 container and said, audience, ask any question that you want. Oh, well, what medication should she be taking? What's her follow-up plan? Were there any complications in any of her surgeries? And within seconds, every answer to every question just appears. They say, oh my God, I can now treat the patient. And so this is real. It is absolutely. It's not perfect, but give us a couple of quarters.Eric Topol (25:31):Yeah, quarters not even years. I think you're putting the finger on something that a lot of people are not aware, which is when you have complex patients like what you just described, that woman, and you have so much information to review, no less the corpus of the medical literature, and you have help with diagnosis treatments that you might not otherwise thought of. It also gets me back to a point I was going to make the machine vision during colonoscopy where it does pick up these polyps, but it was shown that at the end of the day in the afternoon for gastroenterologists that are doing colonoscopies all day, their pickup rate drops down. They get tired, their eyes are just not working as well. And here your machines, they don't get tired. So these things are augmenting the performance of physicians, clinicians across the board potentially.(26:28):And yes, there's a concern as you touched on about confabulation or hallucinations, whatever, but this is a work in progress. There will be GPT-X, BARD-15 or whatever else right now, another area that is hot, which is still very in the earliest nascent stage, is the virtual medical coach. Whereby any of us with all our data, every visit we've ever had, plus our data that's in real time accruing or scans or slides or whatever it is, is all being fed in process with the medical literature and helping us to prevent a condition that we would have high risk to develop or manifest or better management of the various things we do have that we've already declared. What about that, John? Are we going to see virtual medical coaches like the kind we see for going to the airport, or you have an appointment such and such about your daily life, or is that something that is way out there in time?John Halamka (27:37):I know you're going to hate this answer. It depends.Eric Topol (27:41):Okay. I don't hate that. I like it actually. Yeah.John Halamka (27:44):So some years ago, one of my graduate students formed a virtual coaching company, and what he found was patients would often start with a virtual coach, but they wouldn't stick with it because the value add wasn't necessarily there. And that is it wasn't then every day there was something new or actionable. And so if it's few and far between, why do you want to go through the effort of engaging in this? So I think our answer there is we need to make sure that the person who uses it is getting something of value for using it. Reduced insurance rates, free club memberships to a gym, whatever, something of value. So it gets some stickiness.Virtual AI CoachingEric Topol (28:33):Yeah. Well, it's still early and right now, as you well know, it's really confined to certain conditions like diabetes or depression or high blood pressure. But it certainly has the chance in the years ahead to become broad for any individual. And that gets back to the patient scenario that you presented where you had all the data of that woman who presented with weakness as the inputs. And just think about that happening in real time, giving feedback to any given individual, always thinking that it's optional. And as you say, maybe it'd be more elective. There were incentives, and if people don't want it, they don't have to use it, but it's something that's out there dangling as a potential. Well, of the things we've discussed, there are many potential ways that AI can be transformative in the future, both for clinicians, for health systems, for patients. Have I missed anything that you're onto?John Halamka (29:40):Just that in predictive AI, we can judge performance against ground truth. Did you have the disease or not? Did you get a recommendation that was followed up on and it was positive? With generative ai measuring quality and accuracy, doing follow up and oversight is much harder. So I think what you're going to see is FDA and the office of the national coordinator and the White House work through generative AI oversight. It's going to start with, as we've seen voluntary oversight from some of the companies themselves. And it will evolve into maybe some use cases that are considered reasonable practices and others that we defer reasonable practices. Hey, you want an agent that will pre-draft your email and then you just edit it, that's fine. And Mayo is live with that in Epic inbox. How about help you write a letter or help you take, as you say, a very complex medical condition, explain it in eighth grade English or a foreign language. Very good at all of that differential diagnosis, not quite ready yet. And so I think we'll start with the administrative use cases, the things that reduce burden. We'll experiment with differential diagnosis. And I don't think we yet have line of sight to say, actually, we're going to have the generative ai do your diagnosis(31:09):Not there yet,Machines Promoting EmpathyEric Topol (31:10):Right? Perhaps we'll never be, particularly for important diagnoses, maybe for routine things that are not a serious matter. One thing that I didn't anticipate, and I want to get your view. When I wrote deep medicine, I was talking about restoring the patient-doctor relationship and the gift of time that could be garnered from having this machine support. But now we're seeing the evidence that the AI can promote empathy. So for example, reviewing a doctor's note and telling the doctor, you didn't show you're very sensitive. You weren't listening, making suggestions for being a more empathic physician or nurse. Did you foresee that too? Because you've been ahead of the curve on all this stuff.John Halamka (32:04):So here's an interesting question. You and I are physician, scientist, writers. How many physician scientist writers are there? Not so many. So what you get are brilliant math or brilliant science, and it is communicated very badly. So I did not anticipate this, but I'm saying the same thing you are, which is you can take a generative AI and take something that is not very digestible and turn it to something highly readable. And whether that's empathy or clarity or whatever, it actually works really well.Eric Topol (32:43):Yeah. Yeah. I mean, I kind of stunned by this because the machines don't know empathy. They can't feel empathy, but they can promote it. And that's really fascinating. So this has been an uplifting discussion. A lot of the things that's happening now give credit to you that you saw coming long before others, and it's a real joy. So we got to keep up with each other. We got to do some more brainstorming on the things that we haven't discussed today. But thanks so much, John, for joining me and for being such a bright light for the work you're doing with Mayo Clinic as a president of its platform. That's no question. Transforming the future of healthcare.John Halamka (33:25):Well, hey, thanks for having me. And I would say both you and I have taken the digital Hippocratic Oath. We will do no digital harm.Eric Topol (33:33):Love it. Get full access to Ground Truths at erictopol.substack.com/subscribe

This episode features Alexa B. Kimball, MD, MPH, President & CEO, Harvard Medical Faculty Physicians At Beth Israel Deaconess Medical Center. Here, she discusses her background & career, the top 4 issues she's spending her time on, the importance for healthcare leaders to be resourceful & flexible, and more. Want to network with peers and hear more conversations like this? Apply to be one of our complimentary guest reviewers at our upcoming Annual Meeting April 3-6, 2023 here.

Dr. Amy Shah has one of the most unique training backgrounds in the world. She trained at the renowned school of nutrition at Cornell where she graduated Magna Cum Laude and then she went graduate with honors from medical school for her research with her publication “Ct detection of acute myocardial infarction”. After obtaining expertise in both nutrition and medicine, she then completed residency and fellowship at the Harvard hospital Beth Israel Deaconess and Columbia University hospitals respectively. In addition to her clinical work she has written the book called “I'm So Effing Tired” and created amymdwellness.com.She speaks to companies like NBC Universal, Morgan Stanley, Ropes and Gray, Goldman Sachs, and TPG. She has spoken for the Harvard Club and multiple medical conferences. She been on top shows like the Today show and Dr Oz.On This Episode:Amy explains how numerous accomplishments in her career still left her feeling empty.Learn how unhealthy traits can be passed down genetically.Hear how Amy helps clients through one-on-one coaching.Find out how to be happier.Amy talks about the differences between stress, anxiety and depression.Amy breaks down her vision and the routines that are taking her in that direction.Vince and Amy discuss best practices for social media. Key Takeaways:Motivation follows action.Set habits that are non-negotiable.Your feelings are a product of what you focus on.Tweetable Quote:“Hijack your own dopamine."––––––––––Join 100+ ambitious entrepreneurs like yourself who are COMMITTED to growing and scaling successful coaching businesses so that you have a RECORD YEAR IN 2023!In Cancun, from January 19-21, you'll discover the newest strategies and systems you MUST KNOW in order to scale to consistent $10K… $25K… $50K and even $100K months without any more BS “guru coaches” are feeding you.Purchase your ticket to the Cancun Mastermind here: https://go.7figuremastermind.ca/training

Join Dr. Jeffrey Gladden and Max Newlon, the President of BrainCo USA. Max has a Master's from Harvard Graduate School of Education and years of clinical trial experience at Beth Israel Deaconess and Massachusetts General Hospital (MGH). He was the lead coordinator for a $1 million IARPA study on cognitive enhancement and has leadership development industry experience. He is also the President of BrainCo, which grew out of the Harvard Innovation Lab. BrainCo develops cognitive training technology products and applies this expertise in machine learning, design, and neuroscience to create innovative cognitive-based applications. FocusCalm is one of the company's verticals that uses neurofeedback to help users train and optimize their brains. In this episode, you get to learn more about optimizing your life by gaining control of your brain using FocusCalm. Max advocates that your brain is always capable of change and is within your control. Are you interested in optimizing your life, learning about brain modulation, brain reprogramming, and improving the quality of your life? Listen to hear more about shifting your mindset to understand you can change your brain, learn to observe and be aware of your mental state, and deepen your mindfulness.  Listen to this episode to learn about making a hundred, the new thirty, and living beyond 120!    Show notes:    Steve starts out by disclosing Dr. Gladden's current location. (0:28)  Dr. Gladden tells us that brain modulation and brain programming are important for health, longevity, performance, and improving the quality of life. (1:12)  Dr. Gladden reiterates that the fundamental issue with all health and all health optimization is the brain or a function of brain programming and re-programming. (2:07)  Dr. Gladden questions Max about why he decided to focus on the brain. (3:35)  Max recounts an experience he had with his teacher calling his parents in the first grade. (5:02)  Dr. Gladden confirms that what Max is doing now has been a lifelong passion for him. (7:02)  Max explains that many team members have a deep artificial intelligence learning background. (9:25)  Max reveals that the best way to understand the brain is to allow the data to tell us what is happening. (11:15)  Dr. Gladden shares that he agrees with Max that we need to respond in the face of danger. (14:24)  Dr. Gladden points out that some people struggle to meditate. (16:30)  Max refers to studies showing that the more people practice, the better their scores. (18:08)  Max discloses that he likes to know what his brain is like when doing one activity compared to another. (19:55)  Max clarifies that they don't have any data yet to show how the headband helps with a concussion but can definitely help with stress. (22:12)  Dr. Gladden defines the flow state as where people report being most satisfied with their lives. (24:09)  Dr. Gladden communicates that if you can modulate your mind to match the activity, you go into the flow state. (26:18)  Dr. Gladden asks Max about the next big thing he is working on. (28:27)  Max advocates that you can change your brain and that you are not stuck with what you have. (30:32)  Max explains that they have not done any studies on depression. (33:18)                        Visit our website, www.gladdenlongevitypodcast.com, for more information on this episode and other episodes as well.  Follow us on social media!  Instagram: @gladdenlongevitypodcast  Twitter: @GLPodcast_  Facebook: @GladdenLongevityPodcast      For more information on our practice or how to become a client, visit: www.gladdenlongevity.com Call us: 972-310-8916 Or email us: info@gladdenlongevity.com        To learn more about Max and the work he does, check out the following:  Website: https://brainco.tech   |  https://focuscalm.com  Email:  general@brainco.tech |  support@focuscalm.com  Telephone number: (617) 945-2166  IG: @focus_calm   FB: @braincotech | @FocusCalmNeuroWellness  Twitter: @BrainCo_Tech | @focuscalm  LinkedIn: FocusCalm https://www.linkedin.com/company/75526385/admin/        Discount /Affiliate Link:  Longevity10 (10% off of the headband and lifetime subscription)  Link: https://focuscalm.com/discount/Longevity10   

Audible Bleeding editors Matt (@chia_md) and Wen (@WenKawaji) are joined by JVS-VL Editor Anahita Dua (@AnahitaDua), JVS Assistant Editor Dr. Paul Dimuzio (@pdimuziomd) , and JVS Editor-in-Chief Dr. Thomas Forbes (@TL_Forbes) to discuss two great articles in the JVS family of journals.  They're joined by Dr. Steven Deak and Dr. Rens Varkevisser, the first authors of each of the papers discussing polidocanol endovenous microfoam and mortality difference between open and endovascular aneurysm repair in the VQI.   Link to “Treatment of superficial venous insufficiency in a large patient cohort with retrograde administration of ultrasound-guided polidocanol endovenous microfoam versus endovenous laser ablation,” by Deak:  https://doi.org/10.1016/j.jvsv.2021.11.007  Link to “Long-term age-stratified survival following endovascular and open abdominal aortic aneurysm repair,” by Varkevisser et al:  https://doi.org/10.1016/j.jvs.2022.03.867  Show Guests: Dr. Steven Deak is a vascular surgeon who specializes in the treatment of venous disease. He practices at the Deak Vein NJ Clinic. Dr. Rens Varkevisser is a trainee at the Erasmus University medical center in Rotterdam, as well as being a clinical research fellow at the department of vascular and endovascular surgery at the Beth Israel Deaconess medical center. Follow us  @audiblebleeding Learn more about us at  https://www.audiblebleeding.com/about-1/  and #jointheconversation.

My guest today is Dr. Richard Parker, Chief Medical Officer at Arcadia, an exciting venture focused on using "big data" to ensure the right information about care is delivered to the right patient when needed. What a concept! For the math nerds out there, they harness millions of data points—like your diagnosis, medications, zip code, etc.—to create a sort of flowchart and navigation tool. Rich tells me it's not Skynet, and we are not at the dawn of a robot apocalypse. What's even more interesting is how Rich got started in his career in Chinese linguistics and how that enabled him to his role as Chief Medical Officer for Beth Israel Deaconess in Massachusetts. Oh, and we rifle through the 1980s and compare notes on how dangerous playgrounds used to be. Enjoy the show.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

This week, please join Associate Editors Mercedes Carnethon and Karol Watson, as well as Guest Editor Fatima Rodriguez as they present the 2nd annual Disparities Issue. Then join Rishi Wadhera and Ashley Kyalwazi as they discuss their article "Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019." Dr. Mercedes Carnethon: Well, good day listeners. I'm Mercedes Carnethon, and I'm joined by my fellow editors, Karol Watson, and Fatima Rodriguez, Associate Editor and Guest Editor for Circulation. And we'd like to welcome you to Circulation on the Run, for our second annual disparities issue. We have a lot of articles to discuss today, many of which we'll summarize, but we encourage you to access the issue and read the articles. First off, Fatima, I believe you have a paper to discuss. Dr. Fatima Rodriguez: Sure thing, Merci. My first paper is a thought provoking article by Nilay Shah, and co-authors from Northwestern University, that examine factors associated with the racial gap in premature cardiovascular disease. Dr. Fatima Rodriguez: This study used data from a well-known cardiac cohort, that aims to identify factors that begin in young adulthood and predict the development of future coronary artery risk. The objective of this study was to examine the relative contributions of clinical versus social factors, in explaining the persistent black/white gap in premature cardiovascular disease. After following around 5,000 black and white study participants for a median of 34 years, black men and women had a higher risk of premature cardiovascular disease. After controlling for multi-level individual and neighborhood level factors measured in young adulthood, the racial differences in premature cardiovascular disease were attenuated. Dr. Fatima Rodriguez: The authors found that the greater contributors to this racial disparity were not only clinical factors, but also neighborhood and socioeconomic factors. The relative explanatory power of each of these factors varied by men and women. This is really noteworthy, since we spent so much of our time in clinical medicine, focusing on identifying and managing traditional risk factors. But in reality, these structural factors and inequities are critically important to address, and contribute to differences in clinical risk factors downstream. Dr. Mercedes Carnethon: Thank you so much, Fatima. That was a really excellent summary. And now, I'm turning to you, Karol. I'd love to hear what you're going to be talking about today. Dr. Karol Watson: I'd like to discuss the paper, Association of Neighborhood Level Material Deprivation with Atrial Fibrillation Care in a Single-Payer Healthcare System Population Based Cohort Study. This is by Dr. Abdel-Qadir and colleagues. Dr. Karol Watson: So in this study, the author sought to determine whether there was an association between neighborhood material deprivation, by that we mean, inability to attain the basic needs of life and clinical outcomes, in individuals with atrial fibrillation. The kicker here is, they did this in an area with universal healthcare. So they wanted to see, if you took away the differences between the ability to see a physician or get your drugs paid for, if you would see any disparities. Dr. Karol Watson: So they performed a population based cohort study, individuals over the age of 66 years of age with atrial fibrillation, in the Canadian province of Ontario. They have universal healthcare there, and full drug coverage for anyone over 65. The primary exposure was neighborhood material deprivation. That's a metric used to estimate the inability to attain basic material needs, like healthy foods, safe housing. Neighborhoods were categorized by quintile, from the least deprived, quintile one, to the most deprived, quintile five. They find that, among about 350,000 individuals with atrial fibrillation, their mean age was 79, and about half of them were women. Those in the most deprived neighborhoods, quintile five, had a higher prevalence of cardiovascular risk factors and non-cardiovascular work comorbidity, relative to those who were in the least deprived areas. Dr. Karol Watson: Even after adjusting for all the confounders, they found that those in the most deprived neighborhoods had higher hazards of death, stroke, heart failure, and bleeding, relative to those in the least deprived neighborhoods. They also found that, despite having universal healthcare and drug coverage, those in the most deprived neighborhoods were less likely to visit a cardiologist, less likely to receive rhythm control intervention, such as ablation, and have worse outcomes. Dr. Karol Watson: And then, the accompanying editorial by Utibe Essien, he reminds us that intervening only on traditional markers of access, like health insurance and drug costs, may not be sufficient to achieve health equity. We have to address all of the structural needs that make people unable to get good help. Further, he points out that, the association between atrial fibrillation and neighborhood deprivation is very likely true with other cardiovascular conditions, as well. Dr. Karol Watson: So, Merci and Fatima, this just reminds us again, that addressing all the social determinants of health are necessary to achieve the best health outcomes. Dr. Mercedes Carnethon: Thanks so much, Karol. I really appreciate that summary of that important piece, focusing on a different domain of disparity. My first paper is an excellent piece, led by one of my favorite other associate editors at Circulation, Dr. Wendy Post, from Johns Hopkins University. And I see a familiar name on here. That's yours, Karol. You two are joined by an all-star list of authors, to describe race and ethnic differences in all-cause in cardiovascular mortality, in the multi-ethnic study of atherosclerosis. Dr. Mercedes Carnethon: MESA is a longitudinal cohort study that launched in 2000, and recruited just over 6,800 adults who identified as black, white, Hispanic, and Chinese. While the study participants were initially free from cardiovascular disease, over an average of 16 years of follow up, 364 participants died from cardiovascular disease. There are a number of novel findings in this paper that led our editor-in-chief to select it as his pick of the issue. Dr. Mercedes Carnethon: The finding that really stands out to me is, how much of an influence the social determinants of health had on black versus white disparities in cardiovascular mortality. In fact, after adjusting for socioeconomic status, the disparities were nearly eliminated. Other critically important findings are that, the oft described Hispanic paradox of lower cardiovascular mortality in Hispanics, as compared with white adults, was demonstrated in this population. And finally, we have longitudinal data on Asians living in the United States. Asian participants in MESA had similar rates of cardiovascular disease mortality as their white counterparts. There's so much to learn in this well designed cohort study, and so many hypotheses about how social determinants and structural racism influence the disparities that we see. Dr. Mercedes Carnethon: So Fatima, I'd like to turn to you next. What else do you have to share? Dr. Fatima Rodriguez: Thank you, Merci. My second paper is a research letter for my home institution of Stanford University, led by my colleague, Dr. Shoa Clarke, discussing how race and ethnicity stratification for polygenic risk course, may mask disparities among Hispanic individuals. Dr. Fatima Rodriguez: This study used data from the Million Veteran Program, to determine how self-identified race and ethnicity impact the performance of polygenic risk scores in predicting coronary artery disease. Dr. Fatima Rodriguez: The investigators found, that the current polygenic risk scores predict coronary artery disease similarly well in Hispanic and non-Hispanic white individuals. However, what I found most interesting, is that there was so much more heterogeneity among Hispanic individuals as measured by K-Means clustering, than among non-Hispanic white individuals. And this study really confirms that there is much more heterogeneity within populations than between populations. And this is particularly true as we think of the extreme diversity of Hispanic populations. Lumping Hispanic populations into one category, may mask important differences in cardiovascular risk prediction outcomes, and even the notions of the Hispanic paradox that you just discussed, Merci. Dr. Mercedes Carnethon: I appreciate you bringing that up again, because there are so many different nuances to the observations that we see in these studies. But I'll keep moving, because we have an embarrassment of riches in this wonderful issue. So Karol I'll turn back to you. Dr. Karol Watson: Thanks, Merci. The next paper I'd like to discuss, is an On My Mind piece by Peter Liu and colleagues, and they entitle it, Achieving Health Equities in the Indigenous Peoples of Canada, Learnings Adaptable for Diverse Populations. Now the author's note that, lessons learned about addressing health disparities from indigenous peoples in Canada, can offer a lot of new lessons for other populations where there are similar disparities. They begin by offering historical perspective, and they say that, most of the health to disparities for the indigenous populations originate from early colonization, in dismantling of the sociocultural economic educational and health foundations, the indigenous communities had historically. Dr. Karol Watson: It's true that, that is true in a number of different countries. This is data from Canada, but we can see similar things in the United States. With the recognition of the historical and ongoing social health inequities, the Canadian government initiated what they call, the Truth and Reconciliation Commission, to recommend a path towards reconciliation, to create best practices for engaging indigenous populations. Dr. Karol Watson: For instance, in Canada, any health research or implementation program, requires the direct engagement of indigenous communities and their elders. They have to try to develop culturally safe environment, including what they say, quote unquote, anti-racism and cultural safety education for all, both indigenous and non-indigenous populations. They want to really respect community values, customs and traditions, including the access to traditional foods, and healing practices, and the support from elders. So they really are making it a very important point, that cultural sensitivity is absolutely critical to engaging these populations. You want to jointly collect data whenever available, to track progress and outcomes. And they offer many examples of successful programs developed using these principles, such as the Diabetes and My Nation program, in British Columbia, or the mobile diabetic telehealth clinic. Dr. Karol Watson: They offer discussion of future initiatives as well, that can help other communities in Canada. Such as, there's an initiative addressing hypertension in the Chinese population in Canada. Dr. Karol Watson: So this thoughtful paper, really looks at disparities in unique populations in Canada. More importantly, it offers potential roadmaps for other populations, solutions to address longstanding legacies of racism and colonialism. Dr. Mercedes Carnethon: Thank you so much, Karol, for that description from our neighbors from the north. Dr. Mercedes Carnethon: My second paper is really relevant during this hot month of July, in much of the United States and the upper hemisphere. And that's because Sameed Khatana and colleagues from the University of Pennsylvania, discuss how extreme heat is associated with higher cardiovascular mortality. For those of us who welcome the heat of summer and the opportunity to get out from behind our desks and exposed to some vitamin D, Khatana and colleagues reviewed county level daily data on temperature, and linked those data with mortality rates. Dr. Mercedes Carnethon: But before I summarize the findings, I invite you to California based cardiologists to join me in Chicago, where extreme heat is really only a problem for about 30 days a year. The authors found that between 2008 and 2017, when the heat index was above 90 degrees Fahrenheit, or 32.2 degrees Celsius, there was a significantly higher monthly cardiovascular mortality rate. In total, extreme heat was associated with nearly 6,000 additional deaths from cardiovascular disease. And sadly, black adults, older adults, and men, bore the greatest burden of mortality rates from extreme heat. So, we can all take lessons from that. Dr. Mercedes Carnethon: But turning to you now, Fatima. Dr. Fatima Rodriguez: Thanks so much, Merci. I'm from Florida, so I can definitely relate to the issues of extreme heat, but I'm very happy for the perfect year round weather here in Northern California. Dr. Fatima Rodriguez: My third paper is led by Dr. Zubair (and Chikwe) and colleagues from Cedar Sinai, and it describes changes in outcomes by race, in children listed for heart transplantation in the United States. I won't give all the details, but this research letter really nicely summarizes how the 2016 Pediatric Heart Allocation Policy revisions may have inadvertently widened health disparities between white and non-white children. This article touches on the difference between equality and equity, even in the most well-intentioned national policies. And I invite our listeners to read the full details in this special Circulation edition. Dr. Mercedes Carnethon: Thanks Fatima. Karol. Dr. Karol Watson: The next paper I'd like to discuss, is a community based cluster randomized pilot trial, of a cardiovascular mobile health intervention, preliminary findings of the FAITH! Trial, from LaPrincess Brewer and colleagues from the Mayo Clinic. Dr. Karol Watson: So it's well known that African Americans have suboptimal cardiovascular health metrics, such as less regular physical activity, suboptimal blood pressure levels, suboptimal diets. So the authors of this study hypothesize, that developing a mobile health intervention, in partnership with trusted institutions, such as, African American churches, might be an effective means to promote cardiovascular health in African American patients. So using a community based participatory research approach, they develop the FAITH! trial. FAITH stands for Fostering African American Improvement in Total Cardiovascular Health. The manuscript in this issue reports, feasibility and preliminary efficacy findings from this refined community informed mobile health intervention, using the FAITH! App, developed by the investigators. Dr. Karol Watson: They performed a cluster randomized control trial. Participants from 16 different churches in the Rochester, Minnesota and Minneapolis St. Paul, Minnesota areas. The clusters were randomized to receive the FAITH! App, that was the intervention group, or were assigned to a delayed intervention program. The 10 week intervention feature culturally relative and sensitive information modules, focused on American Heart Association's Life's Simple 7. Primary outcomes were changes in the mean Life Simple 7 score, from baseline to six months post intervention. They enrolled 85 participants, mean age was 52, and about 71% were female. Dr. Karol Watson: At baseline, the mean Life Simple 7 score was 6.8, and 44% of the individuals were characterized as being in poor cardiovascular health. The mean Life Simple 7 score of the intervention group, after the end of the intervention, increased by 1.9 points. In the control comparator group, it only increased by 0.7 point. Highly statistically significant, with P value of less than 0.0001 at six months. Dr. Karol Watson: Now this FAITH! Trial demonstrated preliminary findings, that suggest that a culturally sensitive and mobile health lifestyle intervention could be efficacious, promoting ideal cardiovascular health among African Americans. I think what's so important about this is that, they partnered with a very trusted group, the churches, and getting buy-in to a community that has had many reasons not to trust in the past, I think is critically important. Dr. Mercedes Carnethon: Well, thank you so much, Karol. My third paper is an original research investigation by Anoop Shah and colleagues from the University of Edinburgh, arguing that socioeconomic deprivation is an unrecognized risk factor for cardiovascular disease. Dr. Mercedes Carnethon: In their study, the authors evaluated how risk scores, with and without indicators of socioeconomic deprivation, performed in a population study in Scotland, the Generation Scotland: the Scottish Family Health Study, of over 15,000 adults. Again, I won't give away all the details, so that I keep our listeners excited to read the article, but all risk scores aren't created equally. And the observed versus expected number of events varied, based on whether the risk score included socioeconomic indicators or not. Further, the performance of the risk scores varied, based on the degree of deprivation that participants were currently experiencing. It's a thought provoking piece, that may challenge us to reconsider how we identify risks for cardiovascular disease in the population. Dr. Mercedes Carnethon: And I'm turning to you now, Fatima. Dr. Fatima Rodriguez: Sure thing, Merci. My last paper is led by Dr. Anna Krawisz, and is looking at how differences in comorbidities explain racial disparities in peripheral vascular interventions. This study used Medicare fee for service data from 2016 to 2018, to examine risks of death and major amputation, one year following peripheral endovascular intervention. They found that, black Medicare beneficiaries had higher population level need for peripheral endovascular interventions, and that black race was associated with adverse events following these interventions. However, after adjusting for the higher prevalence of comorbidity, such as diabetes, hypertension, and chronic kidney disease in black populations, this observation was eliminated. Again, like a common theme in many of the articles we've discussed today, this is to suggest, that moving upstream to reduce risk factors is really critical to eliminate disparities in cardiovascular disease outcomes. And this includes the understudy disease of peripheral arterial disease. Black adults were also less likely to be treated with guideline directed medical therapies in this study. Dr. Mercedes Carnethon: Well, thank you so much, Karol and Fatima, for your wonderful summaries of all of the excellent pieces in this issue. Dr. Karol Watson: And I'd like to thank all of the fantastic investigators who submitted their really fantastic work, so that we could produce this issue. And really, keep them coming. We thank you for this. Dr. Mercedes Carnethon: Well, thank you. So now we'll transition to our feature discussion with Drs. Wadhera and Kyalwazi, from Beth Israel Deaconess Medical Center, and the Harvard Medical School. Dr. Mercedes Carnethon: Welcome to this episode of Circulation on the Run podcast. I'm really pleased to host this feature discussion. My name is Mercedes Carnethon, from the Northwestern University Feinberg School of Medicine. And I'm pleased to have with us today, Drs. Ashley Kyalwazi and Rishi Wadhera from Beth Israel Deaconess, and the Harvard Medical School. And they shared with us a really important piece of work for our disparities issue, that is describing disparities in cardiovascular mortality, between black and white adults in the United States from 1999 to 2019. First of all, I really want to thank you both for submitting your important work to circulation. Dr. Rishi Wadhera: Thanks so much Mercedes, and thanks for the opportunity to submit and revise our manuscript. Ms. Ashley Kyalwazi: Thanks so much for having us. Dr. Mercedes Carnethon: Wonderful. I'd like to start out with you Rishi. Tell our listeners about the objectives of your study, and what your motivation was for carrying out this work. Dr. Rishi Wadhera: Well, I think it's been well established that, black adults are disproportionately impacted by cardiovascular disease, and experience worse cardiovascular outcomes, due to systemic inequities and structural racism. And so, the goal of our study was really, to perform a comprehensive national evaluation of how age adjusted cardiovascular mortality rates have changed for black adults, compared with white adults, over the past two decades in the United States, with a focus on some key subgroups, like younger adults and women. Dr. Rishi Wadhera: In addition, because we know that the neighborhood community or environment in which you live in the US, has an immense influence on cardiovascular health, we also examine changes in cardiovascular mortality for black and white adults by geographic region, rurality, and neighborhood racial segregation. And our primary objective was really, to understand whether disparities in cardiovascular outcomes between black and white adults improved, worsened, or didn't change, from 1999 to 2019. Dr. Rishi Wadhera: And there are some reasons to think we might have made progress in narrowing the mortality gap between these groups over this time period. There have been substantial improvements in preventative care and treatments for cardiovascular disease over the past two decades. And the expansion of insurance coverage under the Affordable Care Act, led to increases in access to care, cardiovascular risk factor screening and treatment, particularly, for black adults. At the same time, we know that, black adults were disproportionately affected by the economic recession of 2008, and experienced worsening poverty, job loss, and wealth loss, all of which are inextricably tied to cardiovascular health, and more broadly, health. And so that was our interest in really exploring how disparities in cardiovascular mortality have changed amongst black and white adults between 1999 and 2019. Dr. Mercedes Carnethon: Thank you so much for that summary. It's really nice to have these sort of pieces that really outline for us a lot of data, and across a number of different domains. Because it allows us really, a chance to think about those data, and how we can use those data in order to help improve health. Dr. Mercedes Carnethon: So tell me a little bit, Ashley, about what your study found. Ms. Ashley Kyalwazi: Absolutely. Yeah. So in the United States, overall, we found that age adjusted cardiovascular mortality rates declined for both populations, so both black and white adults, by around 40% from 1999 to 2019. So encouraging declines across the country. We found that these patterns were similar for both women and men, when we stratified by gender, over the 20 year period. While mortality rates declined in all regions, we still did find disparities when we stratified by age. So between the younger and older black women, versus younger and older black men, we found that, younger black men and black women were dying at higher rates, and were at increased risk of death from cardiovascular mortality, compared to younger white women and men, respectively. But we also found that black women and men living in rural areas consistently experienced highest mortality rates. And then finally, black adults living in higher areas of residential racial segregation, and compared to those living in low to moderate areas of residential racial segregation had higher mortality rates, as well. Dr. Mercedes Carnethon: Wow, this is a lot. And it's really describing a lot of disparities across multiple domains that we can easily measure. Which aspects of these results in your work did you find the most surprising, Ashley? Ms. Ashley Kyalwazi: Yeah, I was intrigued, I think overall, by just the gaps. I was very encouraged by, I think, the declines over time. On an absolute scale, the country has made a lot of progress, in terms of reducing cardiovascular mortality rates for both groups. But still, by the end of the study period, there were notable gaps between black adults and white adults. Particularly, between black, younger women and white, younger women, we see that by the end of the study period, black, younger women still remain over two times the risk of death from cardiovascular disease than younger white women. Which I think, leaves something to be desired from a public health and health policy standpoint, with regards to how we're going to kind of decrease these disparities. Dr. Mercedes Carnethon: I wanted to follow up on that point. Why do you think you see such disparities between black and white younger women? I love the opportunity of the podcast to allow authors a chance to speculate, beyond what they would do in the paper. Ms. Ashley Kyalwazi: Absolutely. I think that, there are a lot of great efforts on a national scale right now, to kind of address the disparities between black and white women. The Association of Black Cardiologists, for example, had a whole paper out about ways to really target and provide preventative measures for black women. So for example, working with communities, where there's a high proportion of black women, to figure out what community based research looks like. Engaging with churches, different types of methods, to really understand the barriers that black women face towards obtaining preventative care. Ms. Ashley Kyalwazi: I think the disparities that we are seeing, could potentially parallel well known and documented disparities in maternal health outcomes. So I think, from a perspective of preventative care, really thinking about, what are the barriers to healthy cardiovascular profiles for black women pre and postnatally, to ensure that their cardiovascular health is an actionable before and after the pregnancy? Ms. Ashley Kyalwazi: And then I think, broadly, the challenges that black women face, mirror the challenges of black adults, plus the additions of like social stressors, things that we looked at in this study neighborhood residential racial segregation, access to healthcare, and all of those things kind of contribute to the profile that black women face, in terms of being often, the heads of their households as well, and carrying on a lot of different societal challenges. Dr. Mercedes Carnethon: Thank you so much for that. I really appreciate that. Dr. Mercedes Carnethon: As I read the paper, one of the findings that I found the most surprising, and it was challenging for me to understand, is that while the absolute difference in rates was declining, or getting smaller over time, between black and white men and women, the rate ratios remained elevated across the course of time. I think, these concepts can be a little challenging to understand, not just to me, but to others as well. That when one measure of effect is showing progress, but another is still reporting a disparity. Dr. Mercedes Carnethon: Rishi, could you explain for our listeners, how we can see progress on one metric, but still find a mortality rate ratio that's 1.3 times higher in black, as compared with white men, for example? Dr. Rishi Wadhera: Thanks for that really important question, Mercedes. Just to summarize, we presented two outcomes that compared cardiovascular deaths among black and white adults in our paper, absolute rate differences, and then separately, rate ratios. And I think, both measures provide important complementary insights. I think that, understanding the absolute rate difference in cardiovascular deaths is critically important from a public health perspective, because it characterizes excess deaths experienced by black adults, compared with white adults. The fact that the absolute rate difference in cardiovascular death has narrowed over the past two decades between these groups is positive news. In contrast, the rate ratio provides us with important insights on the relative difference, or disparity or gap, between black and white adults. Dr. Rishi Wadhera: So again, both are important, both provide sort of synergistic and complimentary insights. And just to sort of cement that, as an example, you were talking to Ashley earlier, about some of the patterns we noticed amongst younger black women and white women. The absolute rate difference in cardiovascular deaths between younger black women, compared to younger white women, decrease from 91 per 100,000 in 1999, to about 56 per 100,000 in 2019. And that's good progress. However, our rate ratio analysis indicated that, still in 2019, young black women were 2.3 times more likely to die of cardiovascular causes than young white women. Highlighting that, we still have a lot of work to do, to address disparities between these groups. Some of which, Ashley already talked about. Dr. Mercedes Carnethon: Thank you so much for that excellent explanation. I know it's certainly, I find it alarming to hear, but then I remember I'm actually not young anymore. So maybe this doesn't apply to me quite as much. But no, I appreciate the explanation. Dr. Mercedes Carnethon: So your report was really unique, in that you studied these disparities, as we discussed, across a number of domains, age, geography, even racial residential segregation. Whereas, the pronounced disparities have been reported in a few of the other domains that you studied. I'm really interested in hearing more about racial residential segregation. I think, a lot of people don't fully understand what the concept is, and the ways in which racial residential segregation may contribute to higher rates of cardiovascular death among blacks. Dr. Mercedes Carnethon: Ashley, would you mind explaining to us first, what racial residential segregation is? And then really, how it would contribute to higher rates of cardiovascular death? Ms. Ashley Kyalwazi: Yeah, absolutely. So in its simplest terms, racial residential segregation is just the physical separation of two or more groups by race and/or ethnicity into different neighborhoods. What gets tricky is, like the long history within the United States of how we got to this point, where you see numerous degrees of segregation across the country. Residential racial segregation in the United States dates back to policies pre World War II, that resulted in kind of discriminatory banking practices and policies. For example, reverse red lining and gentrification, much of which the extent still exists today. And that's what we see kind of, I think, in our results when we looked at high versus low to moderate areas of residential racial segregation, and how those kind of track onto the trends that we see in cardiovascular mortality over time. Ms. Ashley Kyalwazi: The residential racial segregation impacts almost every aspect of life. You can imagine where you live, we know definitely impact, for example, your zip code can impact health outcomes. We've seen individual's cardiovascular health kind of trend with something as simple as your zip code. Where you live really does impact your, for example, access to affordable housing, health insurance, where your primary care physician is, whether or not you even have one. What that trip looks like to see your primary care physician, is it hours on end, and unrealistic to get to, or is it just around the corner? Ms. Ashley Kyalwazi: Educational opportunities, which leads to income, which we know is linked to cardiovascular disease employment in all of these aspects. Even access to green space. In some metropolitan areas that are more segregated, we see that, black adults, for example, have less access to green space, and numerous studies have shown that, that does impact overall health, but then also, from a cardiovascular disease perspective as well. So I think that, given that we know that lack of access to all of these key determinants can adversely affect cardiovascular mortality, and just general cardiovascular health, I think is very interesting that we found that, there was this link between high residential racial segregation and cardiovascular mortality. That we definitely can look into more, and understand kind of in more detail, that the mechanisms at play and ways to intervene. Dr. Rishi Wadhera: And just to layer onto and reinforce Ashley's really excellent answer to that question. We know that black adults are more likely to live in disadvantaged neighborhoods, because of the intentionally racist policies that were put in place many decades ago, that Ashley described so well. And black communities and segregated communities, as Ashley mentioned, are less likely to have access to primary care, high quality hospital care, and green spaces, but also, pharmacies and healthy foods. And we also know, there's a lot of empirical work that's shown that black communities, disproportionately experience psychosocial stressors, trauma. Dr. Rishi Wadhera: Also, these communities are disproportionately exposed to climate change, such as extreme heat. There was a recent paper that extreme heat has been linked to increases in cardiovascular mortality, and disproportionately affects black communities. These communities are also disproportionately exposed to pollution. All of these things we know are linked to cardiovascular health, and represent the effects of again, intentionally racist policies that were put into place many decades ago, the effects of which still persists today. Which will require equally intentional policies that aim to dismantle these longstanding effects, if we hope to make progress in advancing health equity, and specifically, cardiovascular health equity. Dr. Mercedes Carnethon: I appreciate the facility with which the two of you address the multiple complex contributors to cardiovascular health. It's even more impressive coming from two clinicians. So I really appreciate you taking the time to explain this. And this is where I really like the opportunity to open up and say, what more do you want your clinical peers to know about? For example, how does this affect the day to day encounters that you have in clinic with black patients, and other patients who've been traditionally underrepresented? How do you hope your clinical peers will use this information to promote cardiovascular health equity? And I'll open it up to either of you to respond. Ms. Ashley Kyalwazi: Yeah, I can get on that one. I think that, the disparities that our paper highlights, really requires a multisystem level approach to tackling, from public health to public policy. But I think at a provider level, to your question, Mercedes, physicians must be able to, I think at first, read the data and understand that these disparities exist. Ms. Ashley Kyalwazi: If there's no insight with regards to the risk profiles, that simply black women and black men have, because of systemic racism, because of these inequities, then I think, we're already kind of steps behind where we need to be. So recognizing disparities in cardiovascular disease burden for black men and women, prioritizing education on cardiovascular risk. A lot of the conditions are preventable with appropriate access to care and education around these topics. And so, providing education about the signs and symptoms of heart disease and treatment options for black men and women. Recognizing the history of medical mistreatment for black adults in this country. And really, tailoring the approach towards the individual who comes into the office, who might have very valid reasons for hesitating to take a medication, or a lot of questions that need time and consideration. Ms. Ashley Kyalwazi: At a research level, I think, more data and resources should be spent on studying risk prevention and treatment for cardiovascular disease in black adults, and really, developing more community based models, that really get at the specific interventions that work within black communities, that are culturally specific, that are targeted and relevant, for the populations that we're talking about. Ms. Ashley Kyalwazi: I think finally, and I'll let Rishi chime in, I think, this is shockingly low level of racial and ethnic representation in the field of cardiology as a whole. And we know that, diversity in healthcare can improve health outcomes. So from a cardiology perspective, I think, training the next generation of black young men and women to take up their seats at the table, and really advocate for some of these issues, alongside individuals who are already doing great work, would be essential towards reducing disparities that we see. And so all of the above, I think, I would encourage for my colleagues. Dr. Mercedes Carnethon: Thank you so much. Rishi, any final thoughts? Dr. Rishi Wadhera: No, I'll just add onto Ashley's again, really outstanding response that, this is a tension we face when we see patients in cardiology clinic all the time. I think, awareness about disparities, and the multiple factors that contribute to disparities in cardiovascular health, particularly, as it relates to race and ethnicity, are increasingly being recognized as they should be. Dr. Rishi Wadhera: And one of the challenges, how much can clinicians do within the bounds of hospital walls? We can make sure that we get patients the treatments they need. We can make sure we screen patients appropriately. But we know, as we've discussed, that so many factors beyond hospital walls, like widening income inequality, that's disproportionately affected black adults, and has been worsening over the last several decades. Widening educational inequality, that again, disproportionately affects black adults, and has been worsening over decades, also affect how. So I think, thinking about how clinicians, researchers, and policy makers, can work together to address some of these challenges, issues, and broader social determinants of health, that also exist outside our clinical practice, or hospital walls, will be really, really important, if we are serious about advancing health equity in this country. Dr. Rishi Wadhera: I don't think, we can operate in silos anymore. In the clinical world, in the research world, in the policy making world, we need more researchers and clinicians to have a seat at the table when it comes to policy making, individuals who understand how all of these complex factors are inextricably tied to one another, so that we can seek and implement solutions that advance cardiovascular health. Dr. Mercedes Carnethon: Thank you so much. The insights that we've gotten, from not only your written work, but even more importantly, this opportunity to speak with you today, and share with our readership, have just been invaluable. And I really appreciate the amount of time that you spent, in preparing the manuscript, and really contextualizing the findings with us today, as well as in writing. So thank you so much for contributing this really important work to our annual disparities issue. Dr. Rishi Wadhera: Thank you so much, Mercedes. We really appreciate all the time you and the Circulation team took to make the manuscript stronger. Ms. Ashley Kyalwazi: Thank you so much for having us. It was truly an honor to have this conversation and to submit our work. Dr. Mercedes Carnethon: Well, thank you. Dr. Mercedes Carnethon: That wraps up our feature discussion for this episode of Circulation on the Run podcast. I'm Mercedes Carnethon, from Northwestern University, Associate Editor and guest editor of the disparities issues. So thank you so much. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors, or of the American Heart Association. For more, please visit hajournals.org.

With a Master's degree from Harvard Graduate School of Education, years of clinical trial experience at Beth Israel Deaconess and Massachusetts General Hospital, and a lead coordinator role for a $1 million IARPA study on cognitive enhancement, it's safe to say that Max Newlon knows a few things about the mind. The president of  BrainCO USA is here today to discuss their flagship brand, FocusCalm, and how you can use this powerful neuroscience based tool (affordably) to unlock your brain's potential.  Listen as he breaks down: Can you really train your brain to become calmer and more focused? [8:33] The key to mastering meditation. [14:50] How you can use neurofeedback to change your brain activity. [18:32] When is the most effective time to meditate? [22:28] How to delay the effects of cognitive decline. [29:07] Using music to activate your genius. [34:47] One of the most powerful tools you can use to change how you think, feel, and perform. [37:15] Sponsors: Optimal Carnivore: Brain Nourish is a revolutionary combination of grass-fed beef brain and lion's mane mushrooms which form the ultimate whole food nootropic to help you build a better brain. Go to amazon.com/optimalcarnivore and use coupon code RENEGADE10 to get your brain firing on all cylinders. BiOptimizers: Get a bottle of their best-selling enzyme supplement included in a bundle worth $81... FOR FREE. An offer too good to pass up. Go to masszymes.com/renegadefree to grab yours while supplies last.  Athletic Greens: Detoxify your body, boost your energy, and strengthen your immune system with just one scoop. Go to athleticgreens.com/jay to find out why once people start taking it, they never stop. 

Can the wearable on your patient's wrist help prevent their next manic episode?On this episode of Quick Takes Dr. Gratzer hosts Dr. John Torous, digital psychiatry expert and the first guest to appear on 3 podcast episodes. They always have plenty to talk about as the field of digital mental health care continues to expand. This time, the primary focus is on wearables and data collection.They discuss how data captured on devices (especially related to sleep and exercise) can potentially improve care – and overall health; the types of “passive data” that can be collected; and the pros (behaviour and environment) and cons (privacy, privacy, privacy!) that come with it.---During another fascinating tech talk between Drs. Gratzer and Torous we learn about:the implications of wearables in mental health carewhat forms they currently take (watches, rings, phones)the types of data that can be collectedsome can benefit treatment of schizophrenia and depressionothers would help provide accurate social determinants databut, in all cases, there may be risk to data and patient privacy to considerhow COVID ignited synchronous digital mental health care via telehealthand how an asynchronous care using data from wearables and apps is due to ignite next.---Hear more from Dr. John Torous on previous episodes of Quick Takes:Episode 3: What all physicians need to know about digital psychiatry.Episode 11: What all physicians need to know about mental health apps.---Follow us on Twitter

Today we bring you the second half of Harry's conversation with Dave deBronkart, better known as E-Patient Dave for all the work he's done to help empower patients to be more involved in their own healthcare. If you missed Part 1 of our interview with Dave, we recommend that you check that out before listening to this one. In that part, we talked about how Dave's own brush with cancer in 2007 turned him from a regular patient into a kind of super-patient, doing the kind of research to find the medication that ultimately saved his life. And we heard from Dave how the healthcare system in the late 2000s was completely unprepared to help consumers like him who want to access and understand their own data.Today in Part 2, we'll talk about how all of that is gradually changing, and why new technologies and standards have the potential to open up a new era of participatory medicine – if, that is, patients are willing to do a little more work to understand their health data, if innovators can get better access to that data, and if doctors are willing to create a partnership with the patients over the process of diagnosis and treatment.Please rate and review The Harry Glorikian Show on Apple Podcasts! Here's how to do that from an iPhone, iPad, or iPod touch:1. Open the Podcasts app on your iPhone, iPad, or Mac. 2. Navigate to The Harry Glorikian Show podcast. You can find it by searching for it or selecting it from your library. Just note that you'll have to go to the series page which shows all the episodes, not just the page for a single episode.3. Scroll down to find the subhead titled "Ratings & Reviews."4. Under one of the highlighted reviews, select "Write a Review."5. Next, select a star rating at the top — you have the option of choosing between one and five stars. 6. Using the text box at the top, write a title for your review. Then, in the lower text box, write your review. Your review can be up to 300 words long.7. Once you've finished, select "Send" or "Save" in the top-right corner. 8. If you've never left a podcast review before, enter a nickname. Your nickname will be displayed next to any reviews you leave from here on out. 9. After selecting a nickname, tap OK. Your review may not be immediately visible.That's it! Thanks so much.Full TranscriptHarry Glorikian: Hello. I'm Harry Glorikian.Welcome to The Harry Glorikian Show, the interview podcast that explores how technology is changing everything we know about healthcare.Artificial intelligence.Big data.Predictive analytics.In fields like these, breakthroughs are happening much faster than most people realize. If you want to be proactive about your own healthcare and the healthcare of your loved ones, you'll need to some of these new tips and techniques of how medicine is changing and how you can take advantage of all the new options.Explaining this approaching world is the mission of the new book I have coming out soon, The Future You. And it's also our theme here on the show, where we'll bring you conversations with the innovators, caregivers, and patient advocates who are transforming the healthcare system and working to push it in positive directions.In the previous episode we met Dave deBronkart, better known as E-Patient Dave for all the work he's done to help empower patients to be more involved in their own healthcare. If you missed it, I'm gonna recommend that you listen to the first discussion, and then come back here.We talked about how Dave's own brush with cancer in 2007 turned him from a regular patient into a kind of super-patient, doing the kind of research to find the medication that ultimately saved his life. And we heard from Dave how the healthcare system in the late 2000s was completely unprepared to help consumers like him who want to access and understand their own data.Today in Part 2, we'll talk about how all of that is gradually changing, and why new technologies and standards have the potential to open up a new era of participatory medicine – if, that is, patients are willing to do a little more work to understand their health data, if innovators can get better access to that data, and if doctors are willing to create a partnership with the patients over the process of diagnosis and treatment.We'll pick up the conversation at a spot where we were talking about that control and the different forms it's taken over the years.Harry Glorikian: You've observed like that there's some that there's this kind of inversion going on right now where for centuries doctors had sole control over patient data and sole claims to knowledge and authority about how patients should be treated. But now patients may have more detailed, more relevant and more up to date data than your doctors does. Right. You've talked about this as a Kuhnian paradigm shift, if I remember correctly, where patients are the anomalies, helping to tear down an old paradigm, you know. Walk us through the history here. What was the old paradigm and what's the new paradigm and what are you some of your favorite examples of this paradigm shift?Dave deBronkart: Well, so I want to be clear here. I have the deepest admiration for doctors, for physicians and for licensed practitioners at all levels for the training that they went through. I don't blame any of this on any of them. I did a fair amount of study about what paradigms are Thomas Kuhn's epic book The Structure of Scientific Revolutions, like discovering that the Earth isn't the center of the solar system and things like that. The paradigm is an agreement in a scientific field about how things work. And it is the platform, the theoretical model on which all research and further study is done. And these anomalies arise when scientists operating in the field keep finding outcomes that disagree with what the paradigm says. So in the case of the planets circling the earth and the how the solar system works. They discovered that Mars and other planets all of a sudden would stop orbiting and when they would do a little loop de loop. I mean, that's what they observed. And they came up with more and more tortured explanations until finally, finally, somebody said, hey, guess what? We're all orbiting the sun. Now, the paradigm inn health care has been that the physician has important knowledge. Lord knows that's true. The physician has important knowledge and the patient doesn't and can't. Therefore, patient should do as they're told, so called compliance, and should not interfere with the doctors doing their work. Well, now along comes things like all of those things that I mentioned that the patient community told me at the beginning of my cancer. None of that is in the scientific literature. Even here, 15 years later, none of it's in the literature. What's going on here? Here's that first clunk in the paradigm. Right. And we have numerous cases of patients who assisted with the diagnosis. Patients who invented their own treatment. And the shift, the improvement in the paradigm that we have to, where just any scientific thinker -- and if you want to be a doctor and you don't want to be a scientific thinker, then please go away -- any scientific thinker has to accept is that it's now real and legitimate that the patient can be an active person in healthcare.Dave deBronkart: Yeah, I mean, you've said you don't have to be a scientist or a doctor anymore to create a better way to manage a condition. So, I mean, it's interesting, right? Because I always think that my doctor and I are partners in this together.Dave deBronkart: Good participatory medicine. Perfect.Harry Glorikian: You know, he has knowledge in certain places I definitely don't. But there are things where him and I, you know, do talk about things that were like, you know, we need to look into that further. Now, I'm lucky I've got a curious doctor. I found somebody that I can partner with and that I can think about my own health care in a sort of different way. But I mean, sometimes he doesn't have all the answers and we have to go search out something. You know, I was asking him some questions about HRV the other day that, you know, he's like, huh, let me let me ask a few cardiologists, you know, to get some input on this. So do you see that, I mean, I see that as the most desired outcome, where a patient can have their record. They're not expected to go and become a physician at that level of depth, but that the physicians who also have the record can work in a participatory way with the patient and get to a better outcome.Dave deBronkart: Exactly. And the other thing that's happened is and I've only recently in the last year come to realize we are at the end of a century that is unique in the history of humanity until science got to a certain point in the late 1800s, most doctors, as caring as they were, had no knowledge of what was going wrong in the body with different diseases. And then and that began a period of many decades where doctors really did know important things that patients had no access to. But that era has ended. All right, we now have more information coming out every day than anyone can be expected to keep up with. And we now are at a point also where we've seen stories for decades of patients who were kept alive. But at what cost? Right. Well, and we now we are now entering the point where the definition of best care cannot be made without involving the patient and their priorities. So this is the new world we're evolving into, like and Dr. Sands wears a button in clinic that says what matters to you?Harry Glorikian: So I mean, one of the other, based on where you're going with this, I think is you know, there are some movements that have been arising over the years. I don't know, maybe you could talk about one of them, which is OpenAPS. It's an unregulated, open source project to build an artificial pancreas to help people with type 1 diabetes. And I think it was Erich von Hippel's work on patient driven innovation. I talk in my book about, and I ask whether we should be training people to be better patients in the era of, say, A.I. and other technologies. What do you think could be done better to equip the average patient with to demand access to patient data, ask their doctors more important questions, get answers in plain English. You know, be more collaborative. What do you think is going to move us in that direction faster or more efficiently, let's say?Dave deBronkart: Well, I want to be careful about the word better, because I'm very clear that my preferences are not everyone's preferences. Really, you know, autonomy means every person gets to define their own priorities. And another thing is one of the big pushbacks from the hospital industry over the last 10 years as medical records, computers were shoved down their throats along with the mandate that they have to let patients see their data in the patient portal was a complaint that most patients aren't interested. Well, indeed, you know, I've got sorry news for you. You know, when I worked in the graphic arts industry, I worked in marketing, people don't change behavior or start doing something new until they've got a problem. If it's fun or sexy, you know, then they'll change, they'll start doing something new. What we need to do is make it available to people. And then when needs arise, that gets somebody's attention and they're like, holy crap, what's happening to my kid? Right. If they know that they can be involved, then they can start to take action. They can learn how to take action. It's having the infrastructure available, having the app ecosystem start to grow, and then just having plain old awareness. Who knows? Maybe someday there will be a big Hollywood movie where people where people learn about stories like that and. You know, from that I mean that I think nature will take its course.Harry Glorikian: Well, it's interesting because I recently interviewed a gentleman by the name of Matthew Might. He's a computer scientist who became a surrogate patient advocate for his son, Bertrand, who had a rare and undiagnosed genetic disorder that left him without an enzyme that breaks down junk protein in the cells. But he, you know, jumped in there. He did his own research found in over-the-counter drug, Prevacid of all drugs., that could help with Bertrand's deficiency. But, I mean, Dave, you know, Matt is a, he was a high-powered computer scientist who wasn't afraid to jump in and bathe in that, you know. Is that the type of person we need? Is that a cautionary tale, or an inspiring tale? How do you think about that?Dave deBronkart: Desperate people will bring whatever they have to the situation. And this is no different from, you know, there have been very ordinary people who had saved lives at a car crash because they got training about how to on how to stop bleeding as a Boy Scout. You know, it is a mental trap to say, "But you're different." Ok. Some people said, "Well, Dave, you're an MIT graduate, my patients aren't like you." And people say, well, yeah, but Matt Might is a brilliant PhD type guy. What you mentioned few minutes before gives the lie to all of that, the OpenAPS community. All right, now, these are people you need to know appreciate the open apps world. You need to realize that a person with type 1 diabetes can die in their sleep any particular night. You know, they can even have an alarm, even if they have a digital device connected with an alarm, their blood sugar can crash so bad that they can't even hear the alarm. And so and they got tired of waiting the industry. Year after year after year, another five years will have an artificial pancreas, another five years, and a hashtag started: #WeAreNotWaiting. Now, I am I don't know any of the individuals involved, but I'll bet that every single diabetes related executive involved in this thought something along the lines of, "What are they going to do, invent their own artificial pancreas?" Well, ha, ha, ha, folks. Because as I as I imagine, you know, the first thing that happened was this great woman, Dana Lewis, had a digital insulin pump and a CGM, continuous glucose meter, and her boyfriend, who's now her husband, watched her doing the calculation she had to do before eating a hamburger or whatever and said, "I bet I could write a program that would do that."Dave deBronkart: And so they did. And one thing led to another. His program, and she had some great slides about this, over the course of a year, got really good at predicting what her blood sugar was going to be an hour later. Right. And then they said, "Hmm, well, that's interesting. So why don't I put that in a little pocket computer, a little $35 pocket computer?" The point is, they eventually got to where they said, let's try connecting these devices. All right. And to make a long story short, they now have a system, as you said, not a product, they talked to the FDA, but it's not regulated because it's not a product. Right. But they're not saying the hell with the FDA. They're keeping them informed. What are the scientific credentials of Dana Lewis and her boyfriend, Scott? Dana is a PR professional, zero medical computer or scientific skills? Zero. The whole thing was her idea. Various other people got involved and contributed to the code. It is a trap to think that because the pioneering people had special traits, it's all bogus. Those people are lacking the vision to see what the future you is going to be. See, and the beautiful thing from a disruptive standpoint is that when the person who has the problem gains access to power to create tools, they can take it in whatever direction they want. That's one of the things that happened when typesetting was killed by desktop publishing.Harry Glorikian: Right.Dave deBronkart: In typesetting, they said "You people don't know what you're doing!" And the people said, whatever, dude, they invented Comic Sans, and they went off and did whatever they wanted and the world became more customer centered for them.Harry Glorikian: So. You know, this show is generally about, you know, data, Machine learning and trying to see where that's going to move the needle. I mean, do you see the artificial intelligence umbrella and everything that's under that playing a role to help patients do their own research and design their own treatments?Dave deBronkart: Maybe someday, maybe someday. But I've read enough -- I'm no expert on AI, but I've read enough to know that it's a field that is full of perils of just bad training data sets and also full of immense amounts of risk of the data being misused or misinterpreted. If you haven't yet encountered Cathy O'Neil, she's the author of this phenomenal book, Weapons of Math Destruction. And she said it's not just sloppy brain work. There is sloppy brain work in the mishandling of data in A.I., but there is malicious or ignorant, dangerously ignorant business conduct. For instance, when companies look at somebody who has a bad credit rating and therefore don't give them a chance to do this or this or this or this, and so and they actually cause harm, which is the opposite of what you would think intelligence would be used for.Harry Glorikian: So but then, on the opposite side, because I talk about some of these different applications and tools in in the book where, you know, something like Cardiogram is able to utilize analytics to identify, like it alerted me and said "You know, you might have sleep apnea." Right. And it can also detect an arrhythmia, just like the Apple Watch does, or what's the other one? Oh, it can also sort of alert you to potentially being prediabetic. Right. And so you are seeing, I am seeing discrete use cases where you're seeing a movement forward in the field based on the analytics that can be done on that set of data. So I think I don't want to paint the whole industry as bad, but I think it's in an evolutionary state.Dave deBronkart: Absolutely. Yes. We are at the dawn of this era, there's no question. We don't yet have much. We're just going to have to discover what pans out. Really, I. Were you referring to the Cardia, the Acor, the iPhone EKG device a moment ago?Harry Glorikian: No, there's there's actually an, I've got one here, which is the you know...Dave deBronkart: That's it. That's the mobile version. Exactly. Yeah. Now, I have a friend, a physician friend at Beth Israel Deaconess, who was I just rigidly absolutely firmly trust this guy's brain intelligence and not being pigheaded, he was at first very skeptical that anything attached to an iPhone could be clinically useful. But he's an E.R. doc and he now himself will use that in the E.R. Put the patient's fingers on those electrodes and and send it upstairs because the information, when they're admitting somebody in a crisis, the information gets up there quicker than if he puts it in the EMR.Harry Glorikian: Well, you know, I always try to tell people like these devices, you know, they always say it's not good enough, it's not good enough. And I'm like, it's not good enough today. But it's getting better tomorrow and the next day. And then they're going to improve the sensor. And, yep, you know, the speed of these changes is happening. It's not a 10 year shift. It's it's happening in days, weeks, months, maybe years. But, you know, this is a medical device on my arm as far as I'm concerned.Harry Glorikian: It's a device that does medical-related things. It certainly doesn't meet the FDA's definition of a medical device that requires certification and so on. Now, for all I know, maybe two thirds of the FDA's criteria are bogus. And we know that companies and lobbyists have gamed the system. It's an important book that I read maybe five years ago when it was new, was An American Sickness about the horrifying impacts of the money aspect of health care. And she talked about, when she was talking specifically about device certification, she talked about how some company superbly, and I don't know if they laughed over their three martini lunch or what, some company superbly got something approved by the FDA as saying, we don't need to test this because it's the same as something else.Harry Glorikian: Ok, equivalence.Dave deBronkart: And also got a patent on the same thing for being completely new. Right. Which is not possible. And yet they managed to win the argument in both cases. So but the this is not a medical device, but it is, gives me useful information. Maybe we should call it a health device.Harry Glorikian: Right. Yeah, I mean, there are certain applications that are, you know, cleared by the FDA right now, but, you know, I believe what it's done is it's allowing these companies to gather data and understand where how good the systems are and then apply for specific clearances based on when the system gets good enough, if that makes sense.Dave deBronkart: Yes. Now, one thing I do want to say, there's an important thing going on in the business world, those platforms. You know, companies like Airbnb, Uber, whatever, where they are, a big part of their business, the way they create value is to understand you better by looking at your behavior and not throwing so much irrelevant crap at you. Now, we all know this as it shows up. As you know, you buy something on Amazon and you immediately get flooded by ads on Facebook for the thing that you already bought, for heaven's sake. I mean, how stupid is that? But anyway, I think it's toxic and should be prohibited by law for people to collect health data from your apps and then monetize it. I think that should be completely unacceptable. My current day job is for this company called Pocket Health, where they collect a patient's radiology images for the patient so the patient can have 24/7 access in the cloud. And when I joined there, a friend said, oh, I gather they must make their money by selling the data. Right? And I asked one of the two founding brothers, and he was appalled. That's just not what they do. They have another part of the company. And anybody who gets any medical device, any device to track their health should make certain that the company agrees not to sell it.[musical interlude]Harry Glorikian: Let's pause the conversation for a minute to talk about one small but important thing you can do, to help keep the podcast going. And that's to make it easier for other listeners discover the show by leaving a rating and a review on Apple Podcasts.All you have to do is open the Apple Podcasts app on your smartphone, search for The Harry Glorikian Show, and scroll down to the Ratings & Reviews section. Tap the stars to rate the show, and then tap the link that says Write a Review to leave your comments. It'll only take a minute, but you'll be doing us a huge favor.And one more thing. If you like the interviews we do here on the show I know you'll   like my new book, The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer.It's a friendly and accessible tour of all the ways today's information technologies are helping us diagnose diseases faster, treat them more precisely, and create personalized diet and exercise programs to prevent them in the first place.The book is now available for pre-order. Just go to Amazon and search for The Future You, Harry Glorikian.Thanks. And now back to our show.[musical interlude]Harry Glorikian: You mentioned FHIR or, you know, if I had to spell it out for people, it's Fast Healthcare Interoperability Resource standard from, I think, it's the Health Level 7 organization. What is FHIR? Where did it come from and what does it really enable?Dave deBronkart: So I'll give you my impression, which I think is pretty good, but it may not be the textbook definition. So FHIR is a software standard, very analogous to HTTP and HTML for moving data around the same way those things move data around on the Web. And this is immensely, profoundly different from the clunky, even if possible, old way of moving data between, say, an Epic system, a Cerner system, a Meditech system nd so on. And the it's a standard that was designed and started five or six years ago by an Australian guy named Graham Grieve. A wonderful man. And as he developed it, he offered it to HL7, which is a very big international standards organization, as long as they would make it free forever to everyone. And the important thing about it is that, as required now by the final rule that we were discussing, every medical record system installed at a hospital that wants to get government money for doing health care for Medicare or Medicaid, has to have what's called a FHIR endpoint. And a FHIR endpoint is basically just a plug on it where you can, or an Internet address, the same way you can go to Adobe.com and get whatever Adobe sends you, you can go to the FHIR endpoint with your login credentials and say, give me this patient's health data. That's it. It works. It already works. That's what I use in that My Patient Link app that I mentioned earlier.Harry Glorikian: So just to make it clear to someone that say that's listening, what does the average health care consumer need to know about it, if anything, other than it's accessible? And what's the part that makes you most excited about it?Harry Glorikian: Well, well, well. What people need to know about it is it's a new way. Just like when your hospital got a website, it's a new way for apps to get your data out of the hospital. So when you want it, you know that it has to be available that way. Ironically, my hospital doesn't have a FHIR endpoint yet. Beth Israel Deaconess. But they're required to by the end of the year. What makes me excited about it is that... So really, the universal principle for everything we've discussed is that knowledge is power. More precisely, knowledge enables power. You can give me a ton of knowledge and I might not know what to do with it, but without the knowledge, I'm disempowered. There's no dispute about that. So it will become possible now for software developers to create useful tools for you and your family that would not have been possible 15 years ago or five years ago without FHIR. In fact, it's ironic because one of the earliest speeches I gave in Washington, I said to innovators, data is fuel. Right. We talked about Quicken and Mint. Quicken would have no value to anybody if they couldn't get at your bank information. Right. And that's that would have prevented. So we're going to see new tools get developed that will be possible because of FHIR and the fact that the federal regulations require it.Harry Glorikian: Yeah, my first one of my first bosses actually, like the most brilliant boss, I remember him telling me one at one time, he goes, "Remember something: Knowledge is power." I must have been 19 when he told me that. And I was, you know, it took me a little while to get up to speed on what he meant by that. But so do you believe FHIR is a better foundation for accessing health records than previous attempts like Google Health or Microsoft Health Vault?Dave deBronkart: Well, those are apples and oranges. FHIR is a way of moving the data around. Several years into my "Give me my damn data" campaign, I did a blog post that was titled I Want a Health Data Spigot. I want to be able to connect the garden hose to one place and get all my data flowing. Well, that's what FHIR is now. What's at the other end of the hose? You know, different buckets, drinking glasses, whatever. That's more analogous to Google Health and Health Vault. Google Health and Health Vault might have grown into something useful if they could get all the important information out there, which it turns out was not feasible back then anyway. But that's what's going to happen.Harry Glorikian: What is the evolution you'd like to see in the relationship between the patient and the U.S. health care systems? You know, you once said the key to be would get the money managers out of the room. You know, if you had to sort of think about what you'd want it to evolve to, what would it be?Dave deBronkart: Well, so. There are at least two different issues involved in this. First of all, in terms of the practice of medicine, the paradigm of patient that I mentioned, collaboration, you know, collaboration, including training doctors and nurses on the feasibility and methods of collaboration. How do you do this differently? That won't happen fast because the you know, the I mean, the curriculum in medical schools doesn't change fast. But we do have mid career education and we have people learning practical things. So there's a whole separate issue of the financial structure of the U.S. health system, which is the only one I know in the world that is composed of thousands of individual financially separate organizations, each of which has managers who are required by law to protect their own finances. And the missing ingredient is that as all these organizations manage their own finances, nobody anywhere is accountable for whether care is achieved. Nobody can be fired or fined or put out of business for failing to get the patient taken care of as somebody should have. And so those are those are two separate problems. My ideal world is, remember a third of the US health care spending is excess and somebody a couple of years ago...Guess what? A third of the US health care spending is the insurance companies. Now, maybe the insurance companies are all of the waste. I don't know. I'm not that well-informed. But my point is there is plenty of money there already being spent that would support doctors and nurses spending more time with you and me beyond the 12 or 15 minutes that they get paid for.Harry Glorikian: So it's interesting, right? I mean, the thing that I've sort of my bully pulpit for, for a long time has been, once you digitize everything, it doesn't mean you have to do everything the same way. Which opens up, care may not have to be given in the same place. The business model may now be completely open to shift, as we've seen with the digitization of just about every other business. And so I you know, I worry that the EMRs are holding back innovation and we're seeing a lot of innovation happen outside of the existing rubric, right, the existing ivory towers, when you're seeing drug development using A.I. and machine learning, where we're seeing imaging or pathology scans. I mean, all of those are happening by companies that are accessing this digitized data and then providing it in a different format. But it's not necessarily happening inside those big buildings that are almost held captive by the EMR. Because if you can't access the data, it's really hard to take it to that next level of analytics that you'd like to take it to.Dave deBronkart: Yes, absolutely.Harry Glorikian: I mean, just throwing that out there, I know we've been talking about the system in particular, but I feel that there's the edges of the system aren't as rigid as they used to be. And I think we have a whole ecosystem that's being created outside of it.Harry Glorikian: Absolutely. And the when information can flow you get an increasing number of parties who can potentially do something useful with it, create value with it. And I'm not just talking about financial value, but achieve a cure or something like that. You know, interestingly, when the industry noticed what the open apps people were doing, all of a sudden you could no longer buy a CGM that had the ability to export the data.Harry Glorikian: Right.Dave deBronkart: Hmm. So somebody is not so happy about that. When an increasing number of people can get out data and combine it with their other ideas and skills and try things, then the net number of new innovations will come along. Dana Lewis has a really important slide that she uses in some presentations, and it ties in exactly with Erich von Hippel's user driven innovation, which of course, shows up in health care as patient driven innovation. The traditional industrial model that von Hippel talks about is if you're going to make a car, if you're going to be a company going into the car business, you start by designing the chassis and doing the wheels and designing the engine and so on and so on. And you do all that investment and you eventually get to where you've got a car. All right. Meanwhile, Dana shows a kid on a skateboard who can get somewhere on the skateboard and then somebody comes up with the idea of putting a handle on it. And now you've scooter. Right. And so on. The user driven innovations at every moment are producing value for the person who has the need.Harry Glorikian: Right. And that's why I believe that, you know, now that we've gotten to sort of that next level of of datafication of health care, that these centers have gotten cheaper, easier, more accessible. You know, like I said, I've got a CGM on my arm. Data becomes much more accessible. FHIR has made it easier to gain access to my health record. And I can share it with an app that might make that data more interpretable to me. This is what I believe is really sort of moving the needle in health care, are people like Matthew Might doing his own work where it's it's changing that. And that's truly what I try to cover in the book, is how these data [that] are now being made accessible to patients gives them the opportunity to manage their own health in a better way or more accurately and get ahead of the warning light going on before the car breaks down. But one of the things I will say is, you know, I love my doctor, but, you know, having my doctor as a partner in this is makes it even even better than rather than just me trying to do anything on my own. Dave deBronkart: Of course, of course. Dr. Sands is fond of saying "I have the medical training or diagnosis and treatment and everything, but Dave's the one who's the expert on what's happening in his life." Right. And and I'm the expert on my own priorities.Harry Glorikian: Right. Which I can't expect. I mean, my doctor has enough people to worry about, let alone like, me being his sole, the only thing he needs to think about. So, Dave, this was great. It was great having you on the show. I hope this is one of many conversations that we can have going forward, because I'm sure there's going to be different topics that we could cover. So I appreciate you taking the time and being on the show.Dave deBronkart: Well, and same to you. The this has been a very stimulating I mean, and the you've got the vision of the arriving future that is informed by where we're coming from, but not constrained by the old way of thinking. And that really matters. The reality, the emerging reality, whether anybody knows it or not, is that people with a big problem are able to act now in ways that they weren't before. I mean, another amazing example is a guy in England named Tal Golesworthy has Marfan syndrome. And one problem that people with Marfan syndrome face is aortic dissection. The walls of the aorta split open and it can be pretty quickly fatal. And he describes himself in his TED talk as a boiler engineer. And he says when we have a weak pipe, we wrap it. So he came up with the idea of exporting his CAT scan data or the MRI data of his beating heart and custom printing a fabric mesh to wrap around his aorta. And it's become and medically accepted treatment now. Harry Glorikian: That's awesome, right.Dave deBronkart: This is the data in the hands of somebody with no medical training, just. But see, that's the point. That's the point. He enabled by the data, is able to create real value, and it's now an accepted treatment that's called PEARS and it's been done hundreds of times. And, you know, here's a beautiful, it's sort of like the Dana Lewis skateboard scooter progression, years later, a subsequent scan discovered something unexpected. The mesh fabric has migrated into the wall of his aorta. So he hadn't he now has a know what doctor, what hospital, what medical device company would have ever dreamed of trying to create that? That's the beauty of liberation when data gets into the hands of the innovators.Harry Glorikian: Well, that's something that everybody can take away from today is at least thinking about their data, how it can help them manage their health better or their life better. Obviously, I always say, in cahoots with your doctor, because they have very specific knowledge, but having the data and managing yourself is better than not having the data and not understanding how to manage yourself. So on that note, Dave, thank you so much for the time today. It was great.Dave deBronkart: Thank you very much. See you next time.Harry Glorikian:That's it for this week's episode. You can find past episodes of The Harry Glorikian Show and MoneyBall Medicine at my website, glorikian.com, under the tab Podcasts.Don't forget to go to Apple Podcasts to leave a rating and review for the show.You can find me on Twitter at hglorikian. And we always love it when listeners post about the show there, or on other social media. Thanks for listening, stay healthy, and be sure to tune in two weeks from now for our next interview.

Learn about the six-year integrated plastic surgery residency program at Harvard / Beth Israel Deaconess Medical Center, in Boston, Massachusetts, with Dr. Amer Nassar, Dr. Kai Chow, and Dr. Helen Xun. Recorded in September 2021.

The podcast is back with a new name and a new, expanded focus! Harry will soon be publishing his new book The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer. Like his previous book MoneyBall Medicine, it's all about AI and the other big technologies that are transforming healthcare. But this time Harry takes the consumer's point of view, sharing tips, techniques, and insights we can all use to become smarter, more proactive participants in our own health. The show's first guest under this expanded mission is Dave deBronkart, better known as "E-Patient Dave" for his relentless efforts to persuade medical providers to cede control over health data and make patients into more equal partners in their own care. Dave explains how he got his nickname, why it's so important for patients to be more engaged in the healthcare system, and what kinds of technology changes at hospitals and physician practices can facilitate that engagement. Today we're bringing you the first half of Harry and Dave's wide-ranging conversation, and we'll be back on October 12 with Part 2.Dave deBronkart is the author of the highly rated Let Patients Help: A Patient Engagement Handbook and one of the world's leading advocates for patient engagement. After beating stage IV kidney cancer in 2007, he became a blogger, health policy advisor, and international keynote speaker, and today is the best-known spokesman for the patient engagement movement. He is the co-founder and chair emeritus of the Society for Participatory Medicine, and has been quoted in Time, U.S. News, USA Today, Wired, MIT Technology Review, and the HealthLeaders cover story “Patient of the Future.” His writings have been published in the British Medical Journal, the Patient Experience Journal,  iHealthBeat, and the conference journal of the American Society for Clinical Oncology. Dave's 2011 TEDx talk went viral, and is one the most viewed TED Talks of all time with nearly 700,000 views.Please rate and review The Harry Glorikian Show on Apple Podcasts! Here's how to do that from an iPhone, iPad, or iPod touch:1. Open the Podcasts app on your iPhone, iPad, or Mac. 2. Navigate to The Harry Glorikian Show podcast. You can find it by searching for it or selecting it from your library. Just note that you'll have to go to the series page which shows all the episodes, not just the page for a single episode.3. Scroll down to find the subhead titled "Ratings & Reviews."4. Under one of the highlighted reviews, select "Write a Review."5. Next, select a star rating at the top — you have the option of choosing between one and five stars. 6. Using the text box at the top, write a title for your review. Then, in the lower text box, write your review. Your review can be up to 300 words long.7. Once you've finished, select "Send" or "Save" in the top-right corner. 8. If you've never left a podcast review before, enter a nickname. Your nickname will be displayed next to any reviews you leave from here on out. 9. After selecting a nickname, tap OK. Your review may not be immediately visible.That's it! Thanks so much.Full TranscriptHarry Glorikian: Hello. I'm Harry Glorikian. Welcome to The Harry Glorikian Show.You heard me right! The podcast has a new name. And as you're about to learn, we have an exciting new focus. But we're coming to you in the same feed as our old show, MoneyBall Medicine. So if you were already subscribed to the show in your favorite podcast app, you don't have to do anything! Just keep listening as we publish new episodes. If you're not a regular listener, please take a second to hit the Subscribe or Follow button right now. And thank you.Okay. So. Why are we rebranding the show?Well, I've got some exciting news to share. Soon we'll be publishing my new book, The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer. It's all about how AI and big data are changing almost everything we know about our healthcare.Now, that might sound a bit like my last book, MoneyBall Medicine. But I wrote that book mainly to inform all the industry insiders who deliver healthcare. Like people who work at pharmaceutical companies, hospitals, health plans, insurance companies, and health-tech startups.With this new book, The Future You, I'm turning the lens around and I'm explaining the impact of the AI revolution on people who consume healthcare. Which, of course, means everyone. That impact is going to be significant, and it's going to change everything from the way you interact with your doctors, to the kind of medicines you take, to the ways you stay fit and healthy.We want you to be prepared for this new world. So we're expanding the focus of the podcast, too. To go along with the new name, we're bringing you interviews with a new lineup of fascinating people who are changing the way patients experience healthcare. And there's nobody better to start out with than today's guest, Dave deBronkart.Dave is best known by the moniker he earned back in the late 2000s: E-Patient Dave. We'll talk about what the E stands for. But all you need to know going in is that ever since 2007, when he survived his own fight with kidney cancer, Dave has been a relentless, tireless advocate for the idea that the U.S. medical system needs to open up so that patients can play a more central role in their own healthcare. He's pushed for changes that would give patients more access to their medical records. And he hasn't been afraid to call out the institutions that are doing a poor job at that. In fact, some folks inside the business of healthcare might even call Dave an irritant or a gadfly. But you know what? Sometimes the world needs people who aren't afraid to shake things up.And what's amazing is that in the years since Dave threw himself into this debate, the world of healthcare policy has started to catch up with him. The Affordable Care Act created big incentives for hospitals and physician practices to switch over to digital recordkeeping. In 2016 the Twenty-First Century Cures Act prohibited providers from blocking access to patients' electronic health information. And now there's a new interface standard called FHIR that promises to do for medical records what HTML and HTTP did for the World Wide Web, and make all our health data more shareable, from our hospital records to our genomics data to the fitness info on our smartphones.But there's a lot of work left to do. And Dave and I had such a deep and detailed conversation about his past work and how patients experience healthcare today that we're going to break up the interview into two parts. Today we'll play the first half of our interview. And in two weeks we'll be back with Part 2. Here we go.Harry Glorikian: Dave, welcome to the show.Dave deBronkart: Thank you so much. This is a fascinating subject, I love your angle on the whole subject of medicine.Harry Glorikian: Thank you. Thank you. So, Dave, I mean, you have been known widely as what's termed as E-patient Dave. And that's like a nickname you've been using in public discussions for, God, at least a decade, as far as I can remember. But a lot of our listeners haven't heard about that jargon word E-patient or know what E stands for. To me, it means somebody who is assertive or provocative when it comes to managing their own health, you know, with added element of being, say, tech savvy or knowing how to use the Internet, you know, mobile, wearable devices and other digital tools to monitor and organize and direct their own care—-all of which happens to describe the type of reader I had in mind when I wrote this new book that I have coming out called The Future You. So how would you describe what E- patient [means]?Dave deBronkart: You know, it's funny because when you see an E-patient or talk with them, they don't stick out as a particularly odd, nerdy, unusual sort of person. But the the term, we can get into its origins back in the 90s someday if you want to, the term has to do with somebody who is involved. What today is in medicine is called patient engagement. And it's funny because to a lot of people in health care, patient engagement means getting the patient to do what they tell us to. Right. Well, tvhere's somebody who's actually an activated, thinking patient, like, I'm engaged in the sense that I want to tell you what's important to me. Right. And I don't just want to do what I'm told. I want to educate myself. That's another version of the E. In general, it means empowered, engaged, equipped, enabled. And these days, as you point out, naturally, anybody who's empowered, engaged and enabled is going to be doing digital things, you know, which weren't possible 20 years ago when the term patient was invented.Harry Glorikian: Yeah, and it's interesting because I was thinking like the E could stand for so many things like, you know, electronic, empowered, engaged, equipped, enabled, right. All of the above. Right. And, you know, I mean, at some point, you know, I do want to talk about access, right, to all levels. But just out of curiosity, right, you've been doing this for a long time, and I'm sure that people have reached out to you. How many E-patients do you think are out there, or as a proportion of all patients at this point?Dave deBronkart: You know, that depends a lot on demographics and stage of life. The, not surprisingly, digital natives are more likely to be actively involved in things just because they're so digital. And these days, by federal policy, we have the ability to look at parts of our medical information online if we want to. As opposed to older people in general are more likely to say just what the doctors do, what they want to. It's funny, because my parents, my dad died a few years ago. My mother's 92. We're very different on this. My dad was "Let them do their work." And my mother is just all over knowing what's going on. And it's a good thing because twice in the last five years, important mistakes were found in her medical record, you know. So what we're at here, this is in addition to the scientific and technological and data oriented changes that the Internet has brought along. We're also in the early stages of what is clearly going to be a massive sociological revolution. And it has strong parallels. I first had this idea years ago in a blog post, but I was a hippie in the 60s and 70s, and I lived through the women's movement as it swept through Boston. And so I've seen lots of parallels. You go back 100 years. I think the you know, we recently hit the 100th anniversary of the 19th Amendment, giving women the right to vote. There were skeptics when the idea was proposed and those skeptics opinions and the things they said and wrote have splendid parallels with many physicians' beliefs about patients.Dave deBronkart: As one example I blogged some years ago, I can send you a link about a wonderful flyer published in 1912 by the National Association Opposed to Women's Suffrage. And it included such spectacular logic as for, I mean, their bullets, their talking points, why we should not give women the vote, the first was "Most women aren't asking for it." Which is precisely parallel to "Most patients aren't acting like Dave, right? So why should we accommodate, why should we adjust? Why should we provide for that? The second thing, and this is another part, is really a nastier part of the social revolution. The second talking point was "Most women eligible to vote are married and all they could do is duplicate or cancel their husband's vote." It's like, what are you thinking? The underlying is we've already got somebody who's voting. Why do we need to bring in somebody else who could only muddy the picture? And clearly all they could do is duplicate or cancel their husband's vote. Just says that the women or the patients, all right, all I could do is get in the way and not improve anything. I bring this up because it's a real mental error for people to say I don't know a lot of E-patients. So it must not be worth thinking about. Harry Glorikian: Yeah, I mean, so, just as a preview so of what we're going to talk about, what's your high-level argument for how we could make it easier for traditional patients to become E-patients?Dave deBronkart: Well, several dimensions on that. The most important thing, though, the most important thing is data and the apps. Harry Glorikian: Yes.Dave deBronkart: When people don't have access to their information, it's much harder for them to ask an intelligent question. It's like, hey, I just noticed this. Why didn't we do something? What's this about? Right. And now the flip side of it and of course, there's something I'm sure we'll be talking about is the so-called final rule that was just published in April of this year or just took effect of this year, that says over the course of the next year, all of our data in medical records systems has to be made available to us through APIs, which means there will be all these apps. And to anybody middle aged who thinks I don't really care that much, all you have to do is think about when it comes down to taking care of your kids or your parents when you want to know what's going on with them. Harry Glorikian: Would you think there would be more E-patients if the health care system gave them easier access to their data? What are some of the big roadblocks right now?Dave deBronkart: Well, one big roadblock is that even though this final federal rule has come out now, the American Medical Group Management Association is pushing back, saying, "Wait, wait, wait, this is a bad idea. We don't need patients getting in the way of what doctors are already doing." There will be foot dragging. There's no question about that. Part of that is craven commercial interests. There are and there have been numerous cases of hospital administrators explicitly saying -- there's one recording from the Connected Health conference a few years ago, Harlan Krumholtz, a cardiologist at Yale, quoted a hospital president who told him, "Why wouldn't I want to make it a little harder for people to take their business elsewhere?"Harry Glorikian: Well, if I remember correctly, I think it was the CEO of Epic who said, “Why would anybody want their data?”Dave deBronkart: Yes. Well, first of all, why I would want my data is none of her damn business. Well, and but that's what Joe Biden -- this was a conversation with Joe Biden. Now, Joe has a, what, the specific thing was, why would you want to see your data? It's 10,000 pages of which you would understand maybe 100. And what he said was, "None of your damn business. And I'll find people that help me understand the parts I want."Harry Glorikian: Yeah. And so but it's so interesting, right? Because I believe right now we're in a we're in a state of a push me, pull you. Right? So if you look at, when you said apps, I think Apple, Microsoft, Google, all these guys would love this data to be accessible because they can then apps can be available to make it more understandable or accessible to a patient population. I mean, I have sleep apps. I have, you know, I just got a CGM, which is under my shirt here, so that I can see how different foods affect me from, you know, and glucose, insulin level. And, you know, I'm wearing my Apple Watch, which tracks me. I mean, this is all interpretable because there are apps that are trying to at least explain what's happening to me physiologically or at least look at my data. And the other day I was talking to, I interviewed the CEO of a company called Seqster, which allows you to download your entire record. And it was interesting because there were some of the panels that I looked at that some of the numbers looked off for a long period of time, so I'm like, I need to talk to my doctor about those particular ones that are off. But they're still somewhat of a, you know, I'm in the business, you've almost learned the business. There's still an educational level that and in our arcane jargon that gets used that sort of, you know, everybody can't very easily cross that dimension.Dave deBronkart: Ah, so what? So what? Ok, this is, that's a beautiful observation because you're right, it's not easy for people to absorb. Not everybody, not off the bat. Look, and I don't claim that I'm a doctor. You know, I still go to doctors. I go to physical therapists and so on and so on. And that is no reason to keep us apart from the data. Some doctors and Judy Faulkner of Epic will say, you know, you'll scare yourself, you're better off not knowing. Well, ladies and gentlemen, welcome to the classic specimen called paternalism. "No, honey, you won't understand." Right now paternal -- this is important because this is a major change enabled by technology and data, right -- the paternal caring is incredibly important when the cared-for party cannot comprehend. And so the art of optimizing and this is where MoneyBall thinking comes in. The art of optimizing is to understand people's evolving capacity and support them in developing that capacity so that the net sum of all the people working on my health care has more competence because I do. Harry Glorikian: Right. And that's where I believe like. You know, hopefully my book The Future You will help people see that they're, and I can see technology apps evolving that are making it easier graphically, making it more digestible so someone can manage themselves more appropriately and optimally. But you mentioned your cancer. And I want to go and at least for the listeners, you know, go a little bit through your biography, your personal history, sort of helping set the stage of why we're having this conversation. So you started your professional work in, I think it was typesetting and then later software development, which is a far cry from E-patient Dave, right? But what what qualities or experiences, do you think, predisposed you to be an E-patient? Is it fair to say that you were already pretty tech savvy or but would you consider yourself unusually so?Dave deBronkart: Well, you know, the unusually so, I mean, I'm not sure there's a valid reason for that question to be relevant. There are in any field, there are pioneers, you know, the first people who do something. I mean, think about the movie Lorenzo's Oil, people back in the 1980s who greatly extended their child's life by being so super engaged and hunting and hunting through libraries and phone calls. That was before there was the Internet. I was online. So here are some examples of how I, and I mentioned that my daughter was gestating in 1983. I took a snapshot of her ultrasound and had it framed and sitting on my office desk at work, and people would say, what's that? Nobody knew that that was going to be a thing now and now commonplace thing. In 1999, I met my second wife online on Match.com. And when I first started mentioning this in speeches, people were like, "Whoa, you found your wife on the Internet?" Well, so here's the thing, 20 years later, it's like no big deal. But that's right. If you want to think about the future, you better be thinking about or at least you have every right to be thinking about what are the emerging possibilities. Harry Glorikian: So, tell us the story about your, you know, renal cancer diagnosis in 2007. I mean, you got better, thank God. And you know, what experience it taught you about the power of patients to become involved in their decision making about the course of treatment?Dave deBronkart: So I want to mention that I'm right in the middle of reading on audio, a book that I'd never heard of by a doctor who nearly died. It's titled In Shock. And I'm going to recommend it for the way she tells the story of being a patient, observing the near fatal process. And as a newly trained doctor. In my case, I went in for a routine physical. I had a shoulder X-ray and the doctor called me the next morning and said, "Your shoulder is going to be fine, but the X-ray showed that there's something in your lung that shouldn't be there." And to make a long story short, what we soon found out was that it was kidney cancer that had already spread. I had five tumors, kidney cancer tumors in both lungs. We soon learned that I had one growing in my skull, a bone metastasis. I had one in my right femur and my thigh bone, which broke in May. I now have a steel rod in my in my thigh. I was really sick. And the best available data, there wasn't much good data, but the best available data said that my median survival. Half the people like me would be dead in 24 weeks. 24 weeks!Harry Glorikian: Yeah.Dave deBronkart: And now a really pivotal moment was that as soon as the biopsy confirmed the disease, that it was kidney cancer, my physician, the famous doctor, Danny Sands, my PCP, because he knew me so well -- and this is why I hate any company that thinks doctors are interchangeable, OK? They they should all fry in hell. They're doing it wrong. They should have their license to do business removed -- because he knew me he said, "Dave, you're an online kind of guy. You might like to join this patient community." Now, think how important this is. This was January 2007, not 2021. Right. Today, many doctors still say stay off the Internet. Dr. Sands showed me where to find the good stuff.Harry Glorikian: Right. Yeah, that's important.Dave deBronkart: Well, right, exactly. So now and this turned out to be part of my surviving. Within two hours of posting my first message in that online community, I heard back. "Thanks for the, welcome to the club that nobody wants to join." Now, that might sound foolish, but I'd never known anybody who had kidney cancer. And here I am thinking I'm likely to die. But now I'm talking to people who got diagnosed 10 years ago and they're not dead. Right? Opening a mental space of hope is a huge factor in a person having the push to move forward. And they said there's no cure for this disease. That was not good news. But the but there's this one thing called high dose Interleukin 2. That usually doesn't work. So this was the patient community telling me usually doesn't work. But if you respond at all, about half the time, the response is complete and permanent. And you've got to find a hospital that does it because it's really difficult. And most hospitals won't even tell you it exists because it's difficult and the odds are bad. And here are four doctors in your area who do it, and here are their phone numbers. Now, ladies and gentlemen, I assert that from the point of view of the consumer, the person who has the need, this is valuable information. Harry, this is such a profound case for patient autonomy. We are all aware that physicians today are very overworked, they're under financial pressure from the evil insurance companies and their employers who get their money from the insurance companies. For a patient to be able to define their own priorities and bring additional information to the table should never be prohibited. At the same time, we have to realize that, you know, the doctors are under time pressure anyway. To make a long story short, they said this this treatment usually doesn't work. They also said when it does work, about four percent of the time, the side effects kill people.Harry Glorikian: So here's a question. Here's a question, though, Dave. So, you know, being in this world for my entire career, it's my first question is, you see something posted in a club, a space. How do you validate that this is real, right, that it's bona fide, that it's not just...I mean, as we've seen because of this whole vaccine, there's stuff online that makes my head want to explode because I know that it's not real just by looking at it. How do you as as a patient validate whether this is real, when it's not coming from a, you know, certified professional?Dave deBronkart: It's a perfect question for the whole concept of The Future You. The future you has more autonomy and more freedom to do things, has more information. You could say that's the good news. The bad news is you've got all this information now and there's no certain source of authority. So here you are, you're just like emancipation of a teenager into the adult life. You have to learn how to figure out who you trust. Yeah, the the good news is you've got some autonomy and some ability to act, some agency, as people say. The bad news is you get to live with the consequences as well. But don't just think "That's it, I'm going to go back and let the doctors make all the decisions, because they're perfect," because they're not, you know, medical errors happen. Diagnostic errors happen. The overall. The good news is that you are in a position to raise the overall level of quality of the conversations.Harry Glorikian: So, you know, talk about your journey after your cancer diagnosis from, say, average patient to E-patient to, now, you're a prominent open data advocate in health care.Dave deBronkart: Yes. So I just want to close the loop on what happened, because although I was diagnosed in January, the kidney came out in March, and my interleukin treatments started in April. And by July, six months after diagnosis, by July, the treatment had ended and I was all better. It's an immunotherapy. When immunotherapy works, it's incredible because follow up scans showed the remaining tumors all through my body shrinking for the next two years. And so I was like, go out and play! And I started blogging. I mean, I had really I had pictured my mother's face at my funeral. It's a, it's a grim thought. But that's how perhaps one of my strengths was that I was willing to look that situation in the eye, which let me then move forward. But in 2008, I just started blogging about health care and statistics and anything I felt like. And in 2009 something that -- I'm actually about to publish a free eBook about that, it's just it's a compilation of the 12 blog posts that led to the world exploding on me late in 2008 -- the financial structure of the U.S. health system meant that even though we're the most expensive system in the world, 50 percent more expensive than the second place country, if we could somehow fix that, because we're the most expensive and we don't have the best outcomes, so some money's being wasted there somewhere. All right. If we could somehow fix that, it would mean an immense amount of revenue for some companies somewhere was going to disappear.Dave deBronkart: Back then, it was $2.4 trillion, was the US health system. Now it's $4 trillion. And I realized if we could cut out the one third that excess, that would be $800 billion that would disappear. And that was, I think, three times as much as if Google went out of business, Apple went out of business and and Microsoft, something like that. So I thought if we want to improve how the system works, I'm happy if there are think tanks that are rethinking everything, but for you and me in this century, we got to get in control of our health. And that had to start with having access to our data. All right. And totally, unbeknownst to me, when the Obama administration came in in early 2009, this big bill was passed, the Recovery Act, that included $40 billion of incentives for hospitals to install medical computers. And one of the rules that came out of that was that we, the patients, had to be able to look at parts of our stuff. And little did I know I tried to use to try to look at my data. I tried to use the thing back then called Google Health. And what my hospital sent to Google was garbage. And I blogged about it, and to my huge surprise, The Boston Globe newspaper called and said they wanted to write about it, and it wasn't the local newspaper, it was the Washington health policy desk. And they put it on Page One. And my life spun out of control.Harry Glorikian: Yeah, no, I remember I remember Google Health and I remember you know, I always try to tell people, medicine was super late to the digitization party. Like if it wasn't for that the Reinvestment and Recovery Act putting that in place, there would still be file folders in everybody's office. So we're still at the baby stage of digitization and then the analytics that go with it. And all I see is the curve moving at a ridiculous rate based on artificial intelligence, machine learning being applied to this, and then the digitized information being able to come into one place. But you said something here that was interesting. You've mentioned this phenomenon of garbage in, garbage out. Right. Can you say more about one of the hospitals that treated you? I think it was Beth Israel. You mentioned Google Health. What went wrong there and what were the lessons you took away from that?Dave deBronkart: Well, there were, so what this revealed to me, much to my amazement, much to my amazement, because I assumed that these genius doctors just had the world's most amazing computers, right, and the computers that I imagined are the computers that we're just now beginning to move toward. Right. RI was wrong. But the other important thing that happened was, you know, the vast majority of our medical records are blocks of text, long paragraphs of text or were back then. Now, it was in a computer then, it wasn't notes on paper, but it was not the kind of thing you could analyze, any more than you could run a computer program to read a book and write a book report on it. And so but I didn't know that. I didn't know what Google Health might do. The next thing that happened was as a result, since Google Health was looking for what's called structured data -- now, a classic example of structured data is your blood pressure. It's fill in a form, the high number, the low number, what's your heart rate? What's your weight, you know? The key value pairs, as some people call them. Very little of my medical history existed in that kind of form. So for some insane reason, what they decided to send Google instead was my insurance billing history.Dave deBronkart: Now, insurance data is profoundly inappropriate as a model of reality for a number of reasons. One of one reason is that insurance form data buckets don't have to be very precise. So at one point I was tested for metastases to the brain to see if I had kidney cancer tumors growing in my brain. The answer came back No. All right. Well, there's only one billing code for it. Metastases to the brain. And that's a legitimate billing code for either one. But it got sent to Google Health as metastases to the brain, which I never had. All right. Another problem is something called up-coding, where insurance billing clerks are trained you can bill for something based on the keywords that the doctors and nurses put in the computer. So at one point during my treatment, I had a CAT scan of my lungs to look for tumors. And the radiologist noted, by the way, his aorta is slightly enlarged. The billing clerk didn't care that they were only checking for kidney cancer tumors. The billing clerk saw aorta, enlarged, aneurysm, and billed the insurance company for an aneurysm, which I never had. Corruption. Corruption. People ask, why are our health care costs so high? It's this system of keyword-driven billing. But then on top of that, I had things that I never had anything like it. There was, when this blew up in the newspaper, the hospital finally released all my insurance billing codes. It turns out they had billed the insurance company for volvulus of the intestine. That's a lethal kink of the intestine that will kill you in a couple of days if it's not treated. Never had anything of the sort. Billing fraud.Harry Glorikian: Interesting.Dave deBronkart: Anyway, because a random patient had just tried to use Google Health and I knew enough about data from my day job to be able to say, "Wait a minute, this makes no sense, why is all this happening?" And I couldn't get a straight answer. You know, it's a common experience. Sometimes you ask a company, "I've got a problem. This isn't right." And sometimes they just blow you off. Well, that's what my hospital did to me. I asked about these specific questions and they just blew me off. So then once it was on the front page of the newspaper, the hospital is like, "We will be working with the E-patient Dave and his doctor." And there's nothing like publicity, huh?[musical interlude]Harry Glorikian: Let's pause the conversation for a minute to talk about one small but important thing you can do, to help keep the podcast going. And that's to make it easier for other listeners discover the show by leaving a rating and a review on Apple Podcasts.All you have to do is open the Apple Podcasts app on your smartphone, search for The Harry Glorikian Show, and scroll down to the Ratings & Reviews section. Tap the stars to rate the show, and then tap the link that says Write a Review to leave your comments. It'll only take a minute, but you'll be doing us a huge favor.And one more thing. If you like the interviews we do here on the show I know you'll   like my new book, The Future You: How Artificial Intelligence Can Help You Get Healthier, Stress Less, and Live Longer.It's a friendly and accessible tour of all the ways today's information technologies are helping us diagnose diseases faster, treat them more precisely, and create personalized diet and exercise programs to prevent them in the first place.The book comes out soon, so keep an eye out for the next announcement.Thanks. And now back to our show.[musical interlude]Harry Glorikian: One of your slogans is "Gimme my damn data," meaning, you know, your patient records. And so can you summarize first, the state of the art prior to this digital transformation? Why was it historically the case that patients didn't have easy access to charts from their doctor's office or their visits? Why has the medical establishment traditionally been reluctant or maybe even unable to share this data?Dave deBronkart: Well, first, I want to explain the origin of that of that term. Because the speech in September of that year that launched the global speaking had that title. What happened was that summer of 2009, my world was spinning out of control as I tried to answer people's questions and get involved in the blogging that was going on and health policy arguments in Washington and so on. And so a real visionary in Toronto, a man named Gunther Eisenbach, who had quite a history in pioneering in this area, invited me to give the opening keynote speech for his annual conference in Toronto that fall. And several times during the summer, he asked me a question I'd never been asked. I came to learn that it was normal, but it was "For our brochure, we need to know what do you want to call the speech? What's the title of the speech?" And I remember very well sitting in my office at work one day saying into the telephone, "I don't know, just call it 'Give me my damn data, because you guys can't be trusted." And much to my amazement, It stuck.Dave deBronkart: I want to be clear. Under the 1996 health information law called hip hop, you are entitled to a copy of every single thing they have about you. All right, and a major reason for that. Back in the beginning was to detect mistakes. So it's interesting because HIPAA arose from health insurance portability. 1996 was when it first became mandatory that you had to be able to take your insurance business elsewhere and therefore your records. And that's the origin of the requirement that anybody who holds your health information as part of your insurance or anything else has to be really careful about not letting it leak out. And therefore and it has to be accurate. Therefore, you have a right to look at it and get any mistakes fixed. But. Foot dragging, foot dragging, foot dragging. I don't want to. As we discussed earlier, there are some doctors who simply wanted to keep you captive. But there are also, the data was also handwritten garbage at times, just scribbles that were never intended to be read by anyone other than the person who wrote the note in the first place. Harry Glorikian: Well, but, you know, I'm not trying to necessarily defend or anything, but but, you know, as you found at Beth Israel Deaconess, and I talk about this in The Future You as well, part of the problem is most of these things that people look at as large electronic health record systems were are still are in my mind designed as accounting and billing systems, not to help the doctors or the patients. And that's still a major problem. I mean, I think until we have, you know, a Satya Nadella taking over Microsoft where he, you know, went down and started rewriting the code for Microsoft Office, you're not going to get to management of patients for the betterment of their health as opposed to let me make sure that I bill for that last Tylenol.Dave deBronkart: Absolutely. Well, and where I think this will end up, and I don't know if it'll be five years or 10 or 20, but where this will end up is, the system as it exists now is not sustainable as a platform for patient-centered care. The early stage that we're seeing now, there is an incredibly important software interface that's been developed in the last five or six years still going on called FHIR, F-H-I-R. Which is part of that final rule, all that. So all of our data increasingly in the next couple of years has to be available through an API. All right. So, yeah, using FHIR. And I've done some early work on collecting my own data from the different doctors in the hospitals I've gone to. And what you get what you get when you bring those all in, having told each of them your history and what medications you're on and so on, is you get the digital equivalent of a fax of all of that from all of them. That's not coordinated, right. The medication list from one hospital might not match even the structure, much less the content of the medication list. And here's where it gets tricky, because anybody who's ever tried to have any mistake fixed at a hospital, like "I discontinued that medicine two years ago," never mind something like, "No, I never had that diagnosis," it's a tedious process, tons of paperwork, and you've got to keep track of that because they so often take a long time to get them fixed. And I having been through something similar in graphic arts when desktop publishing took over decades ago. I really wonder, are we will we ultimately end up with all the hospitals getting their act together? Not bloody likely. All right. Or are we more likely to end up with you and me and all of us out here eventually collecting all the data and the big thing the apps will do is organize it, make sense of it. And here's a juicy thing. It will be able to automatically send off corrections back to the hospital that had the wrong information. And so I really think this will be autonomy enabled by the future, you holding your own like you are the master copy of your medical reality.Harry Glorikian: Yeah, I always you know, I always tell like what I like having as a longitudinal view of myself so that I can sort of see something happening before it happens. Right. I don't want to go in once the car is making noise. I like just I'd like to have the warning light go off early before it goes wrong. But. So you mentioned this, but do you have any are there any favorite examples of patient friendly systems or institutions that are doing data access correctly?Dave deBronkart: I don't want to finger any particular one as doing a great job, because I haven't studied it. Ok. I know there are apps, the one that I personally use, which doesn't yet give me a useful it gives me a pile of fax pages, but it does pull together all the data, it's it's not even an app, it's called My Patient Link. And anybody can get it. It's free. And as long as the hospitals you're using have this FHIR software interface, which they're all required to, by the way, but some still don't. As long as they do this, My Patient Link will go and pull it all together. Now it's still up to you to do anything with it. So we're just at the dawn of the age that I actually envisioned back in 2008 when I decided to do the Google Health thing and the world blew up in my face.Harry Glorikian: Yeah. I mean, I have access to my chart. And, you know, that's useful because I can go look at stuff, but I have to admit, and again, this is presentation and sort of making it easy to digest, but Seqster sort of puts it in a graphical format that's easier for me to sort of absorb. The information is the same. It's just how it gets communicated to me, which is half the problem. But but, you know, playing devil's advocate, how useful is the data in the charts, really? I mean, sometimes we talk as if our data is some kind of treasure trove of accurate, actionable data. But you've helped show that a lot of it could be, I don't want to say useless, but there's errors in it which technically could make it worse than useless. But how do you think about that when you when you think about this?Dave deBronkart: Very good. First note. First of all, you're right. It will...a lot of the actual consumer patient value will, and any time I think about that again, I think a lot of young adults, I think of parents taking care of a sick kid, you know, or middle aged people taking care of elders who have many declining conditions. Right. There's a ton of data that you really don't care about. All right, it's sort of it's like if you use anything like Quicken or Mint, you probably don't scrutinize every detail that's in there and look for obscure patterns or so on. But you want to know what's going on. And here's the thing. Where the details matter is when trouble hits. And what I guarantee we will see some time, I don't know if it'll be five years, 10, or 20, but I guarantee what we will see someday is apps or features within apps that are tuned to a specific problem. If my blood pressure is something I'm.... Six years ago my doctor said, dude, you're prediabetic, your A1C is too high. Well, that all of a sudden brings my focus on a small set of numbers. And it makes it really important for me to not just be tracking the numbers in the computer, but integrate it with my fitness watch and my diet app.Harry Glorikian: Right. Dave deBronkart: Yeah, I lost 30 pounds in a year. And then at the age of 65, I ran a mile for the first time in my life because my behavior changed. My behavior had changed to my benefit, not because of the doctor micromanaging me, but because I was all of a sudden more engaged in getting off my ass and doing something that was important to me.Harry Glorikian: well, Dave, you need to write a diet book, because I could use I could stand to lose like 10 or 20 pounds.Dave deBronkart: Well, no, I'm not writing any diet books. That's a project for another day. Harry Glorikian: That's it for this week's episode. Dave and I had a lot more to talk about, and we'll bring you the second part of the conversation in the next episode, two weeks from now.You can find past episodes of The Harry Glorikian Show and MoneyBall Medicine at my website, glorikian.com. Don't forget to go to Apple Podcasts to leave a rating and review for the show. You can find me on Twitter at hglorikian. And we always love it when listeners post about the show there, or on other social media. Thanks for listening, stay healthy, and be sure to tune in two weeks from now for our next interview. 

Matt Chia and Andy Lazar sit down with Drs. Leila Mureebe, Jeff Siracuse, and Philip Goodney for a panel discussion introducing the VQI and some practical tips on getting started with vascular health services research. Dr. Leila Mureebe (@leils) is an associate professor of surgery in the division of vascular and endovascular surgery at the Duke University School of Medicine.  She completed her medical degree and general surgery residency at the Medical College of Pennsylvania, a vascular research fellowship at Harvard Longwood, and her vascular surgery fellowship at Yale.  She also holds dual master's degrees in public health from the UNC and in management and clinical informatics from Duke. Dr. Jeff Siracuse is an associate professor of surgery and radiology at the Boston University School of Medicine.  He completed his medical degree at the New York Medical College, followed by a general surgery residency at Beth Israel Deaconess, a vascular research fellowship at Harvard Longwood, and a vascular surgery fellowship at the New York-Presbyterian programs.  He also holds an MBA from Boston University and has extensive experience with the VQI data, including being the medical director and regional RAC chair for the Vascular Study Group of New England. Dr. Philip Goodney is a professor of surgery and the associate chair for research at the Dartmouth-Hitchcock Medical center.  He received his medical degree from the University of Connecticut, followed by a general surgery residency and vascular surgery fellowship at Dartmouth.  He completed a special fellowship in outcomes research with the VA Outcomes Group in White River Junction, Vermont, while also receiving a Master's Degree in Evaluative Clinical Sciences.  Among the many key positions he holds in our field, he is the current chair for the national VQI Research Advisory Committee or RAC. Previous Episode - Dr. Jack Cronenwett with the origin story of the VQI Relevant Links: Current SVS Regional Quality Groups Previously approved VQI projects Submit a RAC Proposal + Deadlines JAMA Surgery guide to the VQI SVS Research Opportunities in Vascular Surgery Host Introductions:  Dr. Lazar (@Lazar_surgery)  is a general surgery resident at Morristown Medical Center in New Jersey and completed his second year of vascular surgery research at Columbia University, where - among other projects - he has focused on using the VQI to look at insurance and health disparities.  Dr. Chia (@chia_md) is in his 5th of 7 years in the integrated vascular surgery program at Northwestern University.  He obtained his medical degree from the University of Illinois College of Medicine and also holds a Master's in Health Services and Outcomes Research at Northwestern.  Follow us @audiblebleeding Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Rob Blackburn, CEO of Blackburn Labs & Special Guest Dr. Mark Benson, Director - Preventative Cardiology at Beth Israel Deaconess Medical Center  -  Discuss a joint AI project focused on cardiology patient care.  You are not going to want to miss this episode as Rob and Dr. Benson share how a new App that Blackburn and Beth Israel Deaconess Medical Center are jointly developing focused on predictive and preventative treatment of high blood pressure can potentially revolutionize Evidence Based Blood Pressure Care.John Provides Guest Introductions:  00:37 - 3:15Rob talks about AI failure rates and why they seem to happen:   6:15 - 7:30Bill tee's up a discussion about the joint project & Dr. Benson provides an overview and scope :  8:10 - 10:56Rob gives a detailed view of the App that they are developing and how life changing it can be:  13:46 - 14:45Dr. Benson discusses how the App gains acceptance and adoption and how it's distributed :  14:50 - 16:50Rob and Dr. Benson discuss potential barriers that could become hurdles to making an App like this, and how they get past them:  16:50  -  22:05Bill asks about about what Rob and Dr. Benson see the future of Healthcare as it pertains to AI:   16:50 - 27:20Dr. Benson shares why Doctors are going to embrace this type of AI technology as it will provide the data that Doctors can TRUST.  It's an App that actually delivers data that Doctors need as well as providing transparency as to how the App came to a certain conculsion :   27:30 - 30:20How to reach Rob and Dr. Benson:www.blackburnlabs.com  (all contact info on site)www.bidmc.harvard.eduClosing remarks:  30:08Bob Miller Intro with Music Fade

In this episode of the ASCO Education Podcast, moderator Dr. Annie Im speaks with fellows and training program directors about oncology training during the COVID-19 pandemic. Featuring Drs. Kathryn Bollin (director), Farah Nasraty (fellow), Jonathan Berry (fellow), Nino Balanchivadze (fellow), and Nishin Bhadkamkar (director). Subscribe: Apple Podcasts, Google Podcasts | Additional resources: elearning.asco.org | Contact Us Air Date: 5/26/2021   TRANSCRIPT [MUSIC PLAYING] SPEAKER: The purpose of this podcast is to educate and inform. This is not a substitute for medical care, and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. ANNIE IM: Hello, and welcome to ASCO's podcast episode focused on the impact of the COVID-19 pandemic on oncology fellows and training programs. My name is Dr. Annie Im. And I'm an associate professor of medicine and the Fellowship Program Director at the University of Pittsburgh. I am pleased to be joined by our five guest speakers today. NINA BALANCHIVADZE: Hello my name is Nina Balanchivadze. I'm a second year fellow at Henry Ford Hospital in Detroit, Michigan. JONATHAN BERRY: Hi, my name is Jonathan Berry. I'm a first year fellow at Beth Israel Deaconess in Boston, Massachusetts. NISHIN BHADKAMKAR: Hi, I'm Nishin Bhadkamkar. I'm an associate professor in the departments of general oncology and gastrointestinal medical oncology. I'm at MD Anderson Cancer Center. And I'm the Program Director of the Hematology Oncology Fellowship Program. KATHERINE BOLLIN: Hello, everyone. I'm Katherine Bollin. I'm the Associate Program Director for Hematology Oncology at Scripps MD Anderson Cancer Center in San Diego. And I'm also the Wellness Chair for the GME Division of Physician Wellness, and a medical oncologist specializing in cutaneous oncology. FARAH NASRATY: Hi, Everyone. I'm Farah Nasraty. I'm a third year hematology oncology fellow at Scripps Clinic MD Anderson in San Diego, California. ANNIE IM: Thank you. So let's get right into it. First, let me ask how are training programs adjusted at your institution during the COVID-19 pandemic? What was the impact on learning? What adjustments did your institution make? And what has worked well that you can share with the treating program community? Let's start with Dr. Bhadkamkar. NISHIN BHADKAMKAR: When the pandemic hit us, we obviously had to rapidly make changes to our clinical and educational programs. I think the first change that came about was transitioning to telemedicine for many of our outpatient visits. And obviously this had an impact on outpatient rotations for our trainees. At the same time, we also changed all of our didactic programming to the virtual format. And this also had to be done fairly quickly to meet institutional requirements. And what we found in making these changes was first and foremost on the clinical side that trainees on outpatient rotation definitely had a perception that their learning would be adversely impacted by having less in-person interactions. And so we really relied on our rotation coordinators to make sure that fellows were involved in the telemedicine platforms to talk about decision making, and to interact with the patients. Obviously, there's no way to completely recreate the interaction. But we wanted there to be the element of fellow talking to patient, than fellow talking to the attending, and then all three again coming together to talk about the treatment plan. With regard to education, we certainly found that there was a social element that is important to learning that it was more difficult to recreate on a virtual platform. However, there were certainly advantages to the virtual setting in the sense that it allowed people to connect from different campuses. It allowed some people to participate who perhaps in a live setting would be less likely to speak up. And so using chat features and other elements, we found that there was a segment of our trainees who actually were participating more than they would have in our normal format. So clearly there were advantages and disadvantages. But I think overall it was a necessary change, and one that I think trainees in the end embraced and were able to make the most of. NINA BALANCHIVADZE: We had a lot of the similar changes as described. And I would say that what worked the best was clear communication and clear messages from the program leadership. One of the important things that our program did was we had a town hall like meeting where all fellows got together with program leadership and faculty, and we discussed going forward. And we discussed what changes will be made. And fellows this way felt empowered. We had our voice, and we were part of a decision. As you all know, the pandemic brought shock. And as the pandemic unraveled, in particular, Detroit was one of the hardest hit cities. Therefore, all of these changes I would say got to us before too many places. Another thing that worked well was splitting up the fellow group in three separate groups, which allowed two week blocks. So a group of fellows did inpatient hematology and oncology related work such as consults. In the same groups, there was a fellow who covered the clinic, and saw patients that could not be seen virtually. There was another group that covered the COVID wards. That was the group that was deployed to take care of patients at the front lines. And a third group of fellows were actually at home, and participated in remote and telemedicine type visits. So the way the structure went-- two weeks of being at home doing remote didactics. Then two weeks doing hematology oncology related work. And then two weeks doing COVID related work. Therefore, after kind of going through these phases, it allowed all the fellows to kind of have a time to decompress and decongest. So I think that really worked well for our program. KATHERINE BOLLIN: So we did many of the same things that have been highlighted already and shifting didactics online, and multidisciplinary conferences. And also clinic visits became mostly telemedicine. And we were able to institute technology within the hospital wards to facilitate interactions that may not have been in person being a consultative service as well. So those things went fairly smoothly at our institution where the impact of COVID initially was relatively low compared to other institutions across the country. So we were able to maintain a safe and functional environment. But what's been interesting is that, yes, we've been nimble in making this kind of transition, but now our eyes are open to the advantages of working and functioning in a virtual world. And we're looking at how we might carry this over in a post COVID way. I think that remains to be seen. But it's been wonderful having fellows at different centers coming together over a virtual format not just within our own cancer center from different satellite clinics, but also in combining with other cancer centers. And sharing didactic and multidisciplinary conferences and the like. So I think that the strain and the impact of COVID on our fellowship has been tricky and difficult in many ways. But it's open the door to really facilitating living in a virtual world in the future. ANNIE IM: We know this pandemic has affected everyone in some way. Regarding your personal life and well-being, would you like to share what was particularly challenging during this pandemic? What has been helpful through difficult times? NINA BALANCHIVADZE: I think that pandemic has been challenging on various levels, particularly in personal lives. A lot of the fellows live away from their families or extended family and have children. So the quarantine, and being at home, daycares being closed, I think affected a lot of fellows. In addition, having virtual visits, having teleconferences, is difficult if you have a toddler running around the house. And I think this also puts a whole new layer and dimension to the stress that fellow experienced during this time. And then there was the stress of am I going to get infected? Am I going to infect my children? How am I going to cope? And I believe that these were the questions that everybody had and went through. Personally, what helped me was collaborating and talking to other fellows. I created a Facebook page where I had included a lot of the fellows I knew not only from hematology oncology but as well as from other specialties. So I also took up a hobby. I started gardening and I started taking care of flowers and flowering. And trying to do things that were more family centered to try to get through this difficult time. FARAH NASRATY: I would agree with that. I think COVID of course now we're a year into it, but it brought so many challenges with it all at once. Maybe we were used to dealing with a challenging patient interaction or interpersonal interaction. But it just brought everything together. Not seeing your family, your friends. Not being able to see patients or your co-fellows. And then as we have talked about, just your own fear of getting sick and dying. Or your family member or co-worker getting sick. And so it was just a lot to take all at once. And I think anyone could kind of crack under that pressure almost. And so I kind of used that period initially as a stopping point for myself to kind of regroup, and see where I have resiliency skills or strengths. And where I could build upon that. And at Scripps, at my clinic, we had just recently gone through a resiliency course. So I kind of had those tools ready. But I also spent part of the beginning of COVID taking an online course called The Science of Well-being. It's a free course, it's offered through Yale available online at Coursera. And that was a really helpful tool for me to use then, and to continue to use now. Because I think as medical professionals we had an idea of the handwashing, and the masks, and social distancing. But I think in terms of emotional support, and in terms of our being, I think that also took a hit. And we really needed additional support there. And the course I took online and our course at Scripps, there wasn't necessarily anything you didn't already know. Just general reminders. But I think sometimes that's what we need. Right. Like excess use of social media is bad. Increased sleep is good. But it also opened my eyes to some other ideas that even through such a dark time as COVID something like keeping a gratitude journal, which for me is just like in the Notes app on my iPhone. But just little things like that. What are the small positives I could find in the day when I was going through such a hard time. And I think taking that course, taking the resiliency tools I had, and trying to actively remind myself of that, which I hadn't ever done in the past going through medicine, I think that really helped me kind of get through the day to day struggle. And I still use it today. So it's been really helpful. JONATHAN BERRY: So I actually started fellowship last summer. I'm just in my first year. And so we were already several months into the pandemic by the time we entered our hemog fellowship. And I think the most important kind of support in my personal life was really our program thinking about how we as first year fellows can support, and encourage, and be there for each other. So historically, prior to our year, the first year are almost all in the clinic. And so they share what could probably be best termed a very cozy office or a large closet, which of course, did not meet social distancing rules under the normal kind of new standards. And so there is was great advocacy to get us a different office where we could all be at the same workspace appropriately kind of spread out. But be able to support each other as we go through the challenges of starting this new year, and all of the ups and downs of hemog fellowship. And so that was absolutely huge was having that support at work. And on the same way, having my partner and having my close friends that we only saw each other for the first few months. I think just having those people around who are able to remind you of the world outside of medicine whenever things are really challenging was by far the most important part. And the ways in which we couldn't have those interactions that we would have normally had with far more people were some of the hardest parts. ANNIE IM: Next, I want to ask, how have you coped with remote instruction and limited in-person interaction with peers, patients, and mentors? Any lessons learned from this experience that you'd like to share with others? JONATHAN BERRY: So I think one of our big concerns as I was a new fellow in hemog was with the total change of everything moving to online education, and having less in-person interaction locally and at conferences-- national conferences, which obviously also were happening online-- there is this worry of how this would affect our learning in this pivotal first year. And I think that's something that's continued to be a question. And to be honest, I think I still have some areas where I feel like I might have learned this a lot better if I was able to sit with colleagues around a table, and talk about it in person as opposed to online. But that being said, I think there's definitely been some developments. Some things that I've learned and some things that our program has learned about how to make remote instruction as effective as it can be. I think any time we can get people talking and interacting-- like was mentioned earlier, whenever there is educational sessions that are structured in such a way that they're not just one way conversations, but they're kind of small group conversations, or they have interactive elements, or use breakout rooms effectively, those things are extremely helpful at making remote instruction stick a lot better. I think the other aspect is there are types of conferences and types of lectures that actually seem to work a lot better online. So I found that things like grand rounds and having these speakers who often I would be intimidated to approach in person to ask a question, having them online and being able to pose a question in a chat format is significantly less intimidating. And then we also have the ability of bringing in anyone at any time for grand rounds. You don't have to deal with thinking about travel, and housing, and hotels, and things like that. And so I think some of those sorts of things like invited speakers, the online format of instruction has actually worked a lot better. And I anticipate that some of that might actually stick around. Although hopefully, we will still travel from time to time and see each other at conferences and in each other's institutions as well. NISHIN BHADKAMKAR: I think that each fellowship class experienced the pandemic in a different way. And I think that it was very important for program leaders to think carefully about that the first year fellows who started last July didn't know when they applied they didn't know that they were going to be in the midst of a pandemic. And so there was a different type of experience that they had being apart from their families sometimes unexpectedly compared to other fellowship classes. And we found that it was important to try to maintain social connections within the classes and also among the three classes as much as we could. With regard to virtual instruction, the engagement and interactivity piece became even more critical. When you have in-person instruction, there's a natural flow and the natural dynamic to the learning that I think is conducive to fellows education. And when that piece was lost, it was important that we try to include as many interactive elements using small group sessions, using multidisciplinary sessions, to try to engage fellows in virtual platforms. NINA BALANCHIVADZE: I believe that a pandemic did change our outlook on medicine. And general medicine as well as on our subspecialty training. A lot of us felt lost because some of the procedures were not being done. There was a feeling of, am I going to get enough instruction? Am I going to see enough procedures? And on the flip side, we've all felt that we have had acquired additional points in our training that was important for the future, such as triaging patients better. Which before pandemic, I would have never thought that a patient with cancer on cytotoxic chemotherapy can be seen virtually. And now we had to triage which patients were safe to be seen via televisit, and which patients had to come in. We also honed on our skills on some of the basic general internal medicine issues. And I also think that having this experience and going through deployment opened our eyes to what is it like to be in the shoes of other specialists, such as hospitalists, and emergency room physicians, the infectious disease physician. So I think this period was important for team building. And it was important to further our respect for different subspecialists. So carrying that forward, I think, will be very important for me as a physician and as a specialist. ANNIE IM: What has been the impact of the pandemic on your clinical training? FARAH NASRATY: At my institution, we were relatively spared or fortunate in that they really didn't need a lot of us to come to the inpatient medicine and ICU services, which is different from some of the other colleagues on the call. But I think our biggest change, of course, was the move to telemedicine. I think we're all pretty adept with the internet and computer visits. And that wasn't really the challenge-- the visit itself. I think for me and my co-fellows, it was the loss of the interaction with our attendings that I think was tough. Of course, the educational aspect changed a bit. You were looking up things by yourself. And reading articles by yourself versus doing that with your attending. But I think there's also the loss of that kind of casual back and forth with your attending about your interests, your career goals, maybe mentorship. And just those little pieces that you didn't really have necessarily when you weren't together in the office. Or the same conversations that were lost somewhat with your co-fellows. But I think just as we've all had to do with everything else related to COVID, we adapted to the online situation also. And Dr. Bollin, Dr. Costantini, our program directors, they really made a point to have us carve out some time with our attendings to chat about our patients via email. Or to just call each other on the phone or text each other just to check in and talk. Kind of what we had done in the office. And it was kind of in a different format. But I think we were able to gain back that human interaction that we were all missing, and that we were all craving. So we really made an adjustment to using telemedicine, and to have it kind of be a positive for us at this point. NINA BALANCHIVADZE: In addition, I think, as a first year fellow I was already struggling delivering bad news in person. And now I had to do that in a telemedicine setting was particularly challenging for me. And not having a senior attending physician right there with me made things even more challenging. So I think we all had to navigate. We all had to lean on our attending physicians on some advice. And learn from experiences. And there were days where I would worry as I delivered bad news over the telephone who was with the patient, and how they were going to react with this news. And did they have the support system to take the news? So I think there was a lot of provider angst, and that really added a whole new dimension to the pandemic. ANNIE IM: Doctors Bollin and Nasraty, your institution offers resiliency training. How does has that benefited trainees at your institution? KATHERINE BOLLIN: So the genesis of our implementing the ASCO resiliency course actually came about after I attended the last in-person ASCO Annual Meeting in 2019. Along with experiencing all the wonderful things that we all experienced when we attend that conference with meeting with colleagues from around the globe to learning cutting edge data, et cetera, I also became acutely aware of a phenomenon that before I wasn't really alerted to, which was several of my colleagues were experiencing some pretty interesting signals or signs of burnout. So I became aware of these signals through some different interactions while I was there I came home. Wrote an essay about it. And spoke about this phenomenon with my program director for the fellowship, Dr. Costantini. And she had actually become aware of the resiliency course as a pilot program. So I looked into that. Did some research. Spoke to folks and fellows that had participated in the pilot. And wondered if it was something that we could use at our institution as a proactive means to help people recognize signs of burnout, and address them during their early career and training phase. So that's what we did. I brought in Dr. Nasraty and another one of our fellows to review the outline of the course, which addresses about eight different topics over eight weeks. And we tweaked it a little bit to their liking in ways that we felt could really address topics at hand that we see daily in the clinic. And then we brought in someone from outside of our institution who's a social worker that specializes in relationships. And ended up being a perfect match for leading this course with our fellows. So we implemented this program actually before COVID. And we did pre-surveys, post-surveys, and then we've run the course now another couple of times since COVID. And have been able to look back over time, and see the response among fellows that have repeated the course and those that have been taking it for the first time. And so far, the data is showing us that one of the key takeaways from the course, is that people are much more aware now of the notion of self care and wellness, and the different tools that we can use to help us develop resiliency skills. And now all of us are acutely aware of the physician burnout pandemic since the COVID pandemic. This is something that I think as a tool for physicians in training has great value. And I'll let Dr. Nasraty speak to the specifics on what she and some of the other fellows have gleaned from this course. FARAH NASRATY: So I have a couple different points. I'll start with the first one, I guess. I love our resiliency course. I've taken it a couple times since it started. And I think it's just such a special opportunity that we have. And I would encourage everyone, if they could have that opportunity, to develop their own unique to their program. But one of the things I'd mention is that our instructor had handed out a sheet on the foundations of mindfulness. Just basic concepts. But I've actually since COVID and until this point today, I keep it in my desk within arm's reach. And so when I'm having a tough time, I always refer to that and just look through the sheet. And I think about what she's told me during our course. And a lot of other fellows do that too. We kind of text back and forth about it. So it's not a cure all to have these type of courses. It doesn't take away all stresses that you have in the clinic and at home. But it just creates almost a safety net that now you know what tools you have. And where you can get extra support. And when I think about how it's benefited us as a group, I think from the fellow standpoint, the course really opened my eyes and our eyes to seeing that our peers experience the same struggles that we do. And I think that sounds pretty simple. But I think it's actually a really important point because I think in medicine everyone feels a sense that they always have to be the best version of themselves. And I know I feel that way. And even during COVID felt that way. And I think that's pretty unrealistic to always want to be the person who doesn't make any mistakes, and who doesn't second guess their clinical decisions. And this course kind of opened my eyes to that. That working through the course, we kind of realize as a group that we might need to temper our expectations a bit. And that we need to allow ourselves some grace, especially during COVID. But even after that. And that we need to remind each other and uplift each other that we're doing a good job, and doing good by our patients. And I think we all experience challenges at work and at home during COVID. And in that protected space in our course, we could really discuss these concerns openly with each other, and provide honest feedback to each other. And I think we helped to support and encourage each other. And I've personally left the course feeling inspired to continue to work on myself, and to continue to uplift my colleagues which I think is just as important. So it's been really beneficial to me. ANNIE IM: Finally, I want to ask an important question as we move forward. Do you anticipate that any of the changes implemented to oncology fellowship training during the pandemic will continue in the post-pandemic era? JONATHAN BERRY: So we've talked about telemedicine a good amount here. And I think that that is certainly something that is here to stay. I think thinking of telemedicine as an option for our patients just gives us such a wealth of opportunities to really provide patient centered care. I think as trainees and as oncology fellows it'll be imperative to learn how, as others have discussed, to triage patients and figure out who's appropriate for telemedicine and who's not. But when you consider that so many cancer centers are in major urban centers, and patients may come from hours away to come see us, figuring out when we can spare them a long drive particularly if they may be nearing the end of their life or on hospice care and yet still be able to check in on them and provide the care we need to provide from a distance, I think is just such a wonderful and crucial tool. And so while we look forward to welcoming more and more of our patients back into our clinics again, seeing them in person, giving them hugs, celebrating the wins, I think we'll also continue to connect with them over the phone and over the computer for years to come. NINA BALANCHIVADZE: In addition to incorporating some of the telemedicine visits in our everyday practice. I think teleconferences could stay, and would be welcome. I found myself attending more tumor boards, multidisciplinary tumor boards, because as I'm driving into work I'm able to listen in. And I find that there are a lot more conferences that I can actually attend virtually that I couldn't go to in person. Also, just echoing back to some of the resilience training, and of the things that we do now to learn about caring about ourselves as physicians. And our program, we are developing a position. And we are going to have a fellow who will be the Wellness Director. So therefore, this fellow will be in charge of trying to help create some opportunities for fellows, and get togethers, and some social events for collaboration as well as promote wellness for all the fellows. FARAH NASRATY: I just have one really short point to kind of reiterate what Jonathan said. But I would say that I don't anticipate telehealth to be my future practice every day all day. But I actually did enjoy somewhat getting to see patients in their home environments where they're comfortable. And there's something about them being with their dog, or their family, with their blanket, and kind of in their comfort space. Because they're always coming into our clinic into our sterile environment. And it's never as comfortable as being at home. And I like that part, and kind of learning a little bit about our patients just beyond what we're talking to them about in the clinic. So I do hope that stays around. And especially, as Jonathan said, for our patients that are coming from hours away to give them this opportunity to have better access to health care I also think is really important. So I hope that sticks. KATHERINE BOLLIN: Sure. One comment I was going to make. I think stemming from what we've experienced as physicians and training programs during the pandemic will be truly a lot more attention on physician well-being. So we think there will be a setting where we can implement resiliency courses across the board at institutions or similar kinds of programs to emphasize-- to put attention onto this need. NISHIN BHADKAMKAR: I'm certainly hoping that we are able to maintain some of the initiatives and the lessons that we learned over the last year. I think as others have mentioned, I think the pandemic really forced us to think carefully about the incremental value of in-person interaction. Whether it's in the clinic or in educational activities. And I think we've learned that, yes, there is value with in-person interactions. But perhaps in some situations we overestimate what that value is. And we underestimate what the virtual platform allows us to do. So in terms of conferences for example. As we've all turned to remote conferences, it's hard to say that the educational value of the conference has been diminished. I would say that there's a social element and a networking element to conferences that certainly can't be reproduced virtually. But I think that the ASCO Annual Meeting and the subspecialty meetings are a great example of how we've been able to maintain that educational component for trainees, faculty, and others in the midst of restrictions on in-person activity. ANNIE IM: That's all the time we have for today. I want to thank you all so much for joining us. It will be really important for our community moving forward to continue to share our best practices as we move into this post-pandemic training era. I want to thank all of our wonderful guest speakers for sharing your experiences with us today, and for participating in this episode of the ASCO Education Podcast. SPEAKER: Thank you for listening to this week's episode of the ASCO eLearning weekly podcast. To make us part of your weekly routine, click Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive E-learning Center at elearning.asco.org.

On this Beat episode, Dr. Brian Mitzman, Thoracic Surgeon with University of Utah Health in Salt Lake City, invites on Dr. Elliot Servais to discuss training the next generation of thoracic surgeons. Dr. Servais is a general thoracic surgeon with the Lahey Hospital and Medical Center in Boston, MA. He serves as the Director of Robotic Thoracic Surgery and Vice Chair for Quality and Safety in the Department of Surgery. He not only mentors fellows from the Beth Israel Deaconess training program, but also serves as a national proctor for Intuitive Surgical.

This week features two Feature Discussions. In our first feature discussion, Nikkil Sudharsanan and Associate Editor Ntobeko Ntusi as they discuss the article "Variation in the Proportion of Adults in Need of BP-Lowering Medications by Hypertension Care Guideline in Low- and Middle-Income Countries: A Cross-Sectional Study of 1,037,215 Individuals from 50 Nationally Representative Surveys." Then in our second feature discussion, join author Aloke Finn and Associate Editor Jeffrey Saffitz as they discuss the article "Microthrombi As A Major Cause of Cardiac Injury in COVID-19: A Pathologic Study." One addendum to the Feature Discussion with Drs. Sudharsanan and Ntusi: ·       Dr. Sudharsanan wanted to clarify that treatment needs were determined for each country based on multiple blood pressure measurements taken on the day of the survey; however, all the estimates were based on BP measured on just one day, rather than over several weeks as is done in clinical practice. This is related the final question posed in the first Feature Discussion. TRANSCRIPT BELOW Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts, I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Greg Hundley Associate Editor for the Pauley Heart Center in Richmond, Virginia at VCU Health. Dr. Carolyn Lam: Guess what, Greg, it's another issue with a double feature. We are going to be discussing microthrombi as a major cause of cardiac injury in COVID-19. Dr. Greg Hundley: Yes, Carolyn and our second discussion will be centered on blood pressure lowering in low and middle-income countries. But how about you and I both grab a cup of coffee and jump into the other articles in this issue. Dr. Carolyn Lam: Sure thing. I got my coffee and let's start with gestational diabetes. Now, we know that leads to an earlier onset and heightened risk of type 2 diabetes, which is a strong risk factor for cardiovascular disease. But Greg, do you think that attaining normal glycemia following gestational diabetes can ameliorate the access risk? Dr. Greg Hundley: Carolyn, that's a really great question. I would think so but how about you tell me what these authors found. Dr. Carolyn Lam: Yep. This next paper it's from Dr. Gunderson from Kaiser Permanente, North California and colleagues. They exactly sought to answer the question and realize that it was unclear whether attaining normal glycemia can ameliorate the excess cardiovascular disease risk that's associated with gestational diabetes. So they evaluated gestational diabetes history and glucose tolerance after pregnancy and found out whether or not it was associated with coronary artery calcification in women. The obtained data from the CARDIA study which is a US multicenter community-based perspective cord of young black and white adults age 18 to 30 years at baseline. Dr. Carolyn Lam: This is what they found. Women without previous gestational diabetes showed a greater increase in the risk of coronary artery calcification associated with worsening glucose tolerance. However, women with a history of gestational diabetes had a twofold higher risk of coronary artery calcification across all subsequent levels of glucose tolerance. Midlife atherosclerotic cardiovascular disease risk among women with previous gestational diabetes is therefore not diminished by attaining normal glycemia. And this is discussed in an accompanying editorial by Dr. Jennifer Green from DCRI entitled Cardiovascular Consequences of Gestational Diabetes. Dr. Greg Hundley: Carolyn, well, sounds like I was wrong but our next paper, it's going to review for us a little bit about IgE. Remember that immunoglobulin associated with itching. So Carolyn immunoglobulin E or IgE belongs to a class of immunoglobulins involved in immune response to specific allergens. However, the roles of IgE and IgE receptor in pathological cardiac remodeling and heart failure or a non. So in this study, the investigative team measured serum IgE levels and cardiac IgE receptor expression in diseased hearts from humans and mice. Dr. Carolyn Lam: Oh, Greg, I'm itching to find out what this study showed. Dr. Greg Hundley: Yes, Carolyn, going from the quizmaster now to is it comedy now? Serum IgE levels were significantly elevated in patients with heart failure as well as in two mouse cardiac disease models induced by chronic pressure overload via transverse aortic constriction and chronic angiotensin two infusion. Now, interestingly Carolyn, IgE receptor expression levels were also significantly up-regulated and failing hearts from human and the mouse model. Dr. Greg Hundley: Carolyn, the authors found that IgE induction plays a causative role in pathological cardiac remodeling at least partially via the activation of IgE receptor signaling in cardiac myocytes and cardiac fibroblasts. So future studies are needed to determine if therapeutic strategies targeting the IgE receptor axis and as to whether they may be effective for managing IgE mediated cardiac remodeling. Dr. Carolyn Lam: Fascinating. I never thought of IgE involved in cardiac remodeling. Now, this next paper really interesting. Regulators are always evaluating the use of non-interventional real-world evidence studies to assess the effectiveness of medical products. The RCT DUPLICATE Initiative was formed to use a structured process to design real-world evidence studies to emulate randomized control trials and compare results. Now, this paper represents the first 10 trials emulations in RCT DUPLICATE, and it's from Dr. Jessica Franklin from Brigham and Women's Hospital and Harvard Medical School in Boston and her colleagues. And they did this to evaluate cardiovascular outcomes of antidiabetic and antiplatelet medications. Dr. Greg Hundley: Wow, Carolyn. So how does they do this? Dr. Carolyn Lam: So they use patient level claims data from US Commercial and Medicare-PEERS and implemented inclusion exclusion criteria of the trial selected primary endpoints and compare the populations to emulate those of each of the corresponding randomized controlled trials within the trial mimicking populations, they then conducted propensity score matching to control for more than 120 pre-exposure con founders. Dr. Greg Hundley: So Carolyn, were they able to emulate their randomized clinical trial results? Dr. Carolyn Lam: Now, despite the attempts to emulate the trial design as close as possible, there were still differences between the randomized control trial and the corresponding real-world evidence study population. The regulatory conclusions were equivalent in six of 10 studies. The real-world evidence emulations achieved a hazards ratio estimate that was within the 95% confidence interval from the corresponding trial in 8 of 10 studies. Agreement between the trial and real-world evidence findings varied depending on which agreement metric was used. Dr. Carolyn Lam: Interim findings indicated that selection of active comparative therapies with similar indications and use patterns enhance the validity of the real-world evidence. And so, even in the context of active comparators concordance between trial and real-world evidence findings was not guaranteed partially because trials were not emulated exactly. More trial emulations are needed to understand how often and in what context real-world evidence findings will match the trials. And yet these initial findings of RCT DUPLICATE really indicate circumstances when real-world evidence may offer causal insights where trial data is either not available or cannot be quickly or feasibly generated Dr. Greg Hundley: Well, Carolyn, that is really interesting findings there because we're all trying to decide what to do with these large data sets and combining the results of millions and millions of data points and very interesting findings in this study. How about we see what else is in the issue? Dr. Carolyn Lam: Absolutely. Well, let me start. There's an exchange of letters among doctors Villarreal, Cárdenas Suri, [and] Navarro-Castellanos regarding the Multi-system inflammatory syndrome in children. The ECMO needs and Kawasaki disease likeness. There's also an ECG challenge by Dr. Pillai entitled "A Tale of Two Blocks". Dr. Greg Hundley: Well, Carolyn, I've got a very nice In-Depth review from Dr. Van Belle regarding transcatheter aortic valve replacement in bicuspid aortic valve stenosis. And there's a Research Letter from Dr. Lew entitled “Short-Chain Enoyl-CoA Hydratase Mediates Histone Crotonylation and Contributes to Cardiac Homeostasis.” And then finally, Dr. Nordin Hanson from Amsterdam has a very nice piece on the Clinical Implications of Basic Science Research entitled “DAMPening Mortality in COVID19: Therapeutic Insights from Basic Cardiometabolic Studies on S100A8/A9.” Well, Carolyn, how about we check out the double feature. Dr. Carolyn Lam: Definitely let's go, Greg. Dr. Greg Hundley: Well listeners, we are here for our first feature discussion on this March 9th issue and we have with us Nikkil Sudharsanan from Heidelberg and also our own Associate Editor Ntobeko Ntusi from Cape Town. Welcome gentlemen. Nikkil, could you please describe for us the hypothesis that you wanted to test your study population and your study design? Dr. Nikkil Sudharsanan: Yeah, so for our hypothesis, we really wanted to know, depending on which hypertension treatment guideline you chose, what implications does it have at the population level for the number of people in low and middle-income countries that would require treatment or that you would want to place on treatment. And we were really looking at not just one country, but a whole range of 50 low and middle-income countries. And so our study population is actually from this pretty remarkable data source that combines the World Health Organization surveillance data for many countries with other sources of data, to try to create a comparable almost low and middle-income country super dataset that's specifically designed to answer questions around cardiovascular disease. So our study population was really based on population representative samples for each of the 50 countries we considered. And in most of the countries we focused on the adult population. So those ages 30 and above. Dr. Greg Hundley: And your total sample was over a million participants, correct? Dr. Nikkil Sudharsanan: Yeah, it's a really huge sample. And I think it's a testing to some of these data sources, especially the ones in India and Brazil, but collected just really large sample sizes that contributed to this huge global population. Dr. Greg Hundley: Very nice Nikkil. And what did you find? Dr. Nikkil Sudharsanan: So the big finding is we actually went into it not knowing how the choice or how strong the choice of a blood pressure treatment guideline would be on the number of people that required treatment and were really surprised to see that we took more treatment guidelines, the 2018 American College of Cardiology, American Heart Association guidelines, the kind of typical 140 by 90 blood systolic diastolic blood pressure threshold that you see as part of a lot of guidelines. The UKs NICE guideline and then the WHO Hearts guideline, which is based on their pen and package of essential non-communicable disease interventions. Dr. Nikkil Sudharsanan: And we started a really, really pronounced difference in the proportion and size of the adult population that you would recommend or place under hypertension treatment, depending on which of these guidelines used to decide who gets treatment across these countries. So at the top, we found the American College of Cardiology, American Heart Association guidelines, and for the countries we were considering it put about 27% of women and a really high 35% of men as recommended for blood pressure treatment. Dr. Nikkil Sudharsanan: And then very closely followed to that was the 140, 90 threshold. So it was still high, but not as high, I would think it was around 26% of women and 31%. And then between these two guidelines and the UK NICE and WHO Hearts, there was a really big drop-off in how many people would actually be recommended for blood pressure treatment. Dr. Nikkil Sudharsanan: The NICE guideline, for example, only have 12% of women and about 16% of men and the WHO Hearts is by far the lowest, which only about 10% of women and 11% of men. So I think our first really striking finding was that this choice is not trivial. And depending on which guideline you actually choose to decide who gets treatment in that country, it has really big implications for how many people in that country are going to need treatment. Dr. Greg Hundley: Very good. And Ntobeko, how do you put the results of this study in the context with other research perform to study hypertension? Dr. Ntobeko Ntusi: Thank you, Greg. So we know that although more than 80% of the global battle of Cardiovascular Disease, okay. As in low and middle-income countries, the data around respecters for cardiovascular disease has largely come from high-income countries. And the INTERHEART study was really the first publication about 15 years ago to try and address this question. And it was very apparent both in the INTERHEART study as well as the INTERHEART Africa study of hypertension was one of the key respecters not only for my myocardial infraction, but for cardiovascular disease in general. Dr. Ntobeko Ntusi: In the INTERHEART study hypertension having a hazard ratio of two and the population attributable risk of 17%. And then the INTERHEART Africa study having a hazard ratio of over six. And this paper is really an important application in my view, showing that in a comparison of over a million individuals from 50 countries, there is great variation in the proportion of individuals that need to be treated for hypertension, based on the choice of guideline and definition of hypertension. And if you look at figure one, this is variable from anywhere from 9% to 35%. Dr. Ntobeko Ntusi: The other important contribution of this paper is that the proportion of the population that needs to be treated for hypertension increases with age, which is something that we know but strikingly more than 60% in those over the age of 60 years. And for me, they are really great core key messages that I think are important contributions from this publication. The first one being that the choice of hypertension treatment guideline significantly influences the denominator of what you consider to be hypertensives in your population. The second one is that many people in low and middle-income countries are still unaware of their status of elevated blood pressure and the need for treatment. And I think this is a key point to emphasize. Dr. Ntobeko Ntusi: The third important message is that these first two points I've made have got huge implications for the scale-up costs and healthcare system capacity and that countries need to choose definitions for diseases. And this needs to be aligned with national health policy as well as available resources. And then finally, a key part of the discussion, which I asked the author to address was really around our understanding of the barriers to optimal management of blood pressure in low and middle-income countries and how these gaps can be oppressed. And they speak to the economic and human resources, the health policy, the importance of population screening and importantly education at every level. Dr. Greg Hundley: Very good. Nikkil I'd like to come back to you and then maybe 20 seconds or so, what do you think is the next study that needs to be performed really in this area of research? Dr. Nikkil Sudharsanan: I think there may be two, one is to really build on this in terms of what we showed this is the proportion of people that would require treatment and that's how it varies across these guidelines. I think it's important to also tie that to the resource implications directly, like Dr.Ntusi said, to actually show this guideline would require this many resources versus this many for that guideline. I think that will really help countries in deciding what's actually feasible guideline to implement. Dr. Nikkil Sudharsanan: And the second one, which is I think a much more challenging study to do is just a study of all these guidelines are based on mostly data from high-income countries. And even among these high income countries, there's these discussions on what the appropriate level for treatment is and what point you should initiate treatment. And it seems like this really has not been done with low and middle-income country populations. So we're arguing about four different guidelines that were built for high-income country populations. And I think it would be really important to see some sort of trial or long-term observational study actually in terms of averting cardiovascular disease events which guidelines actually makes the most sense for these countries. Dr. Greg Hundley: Very good. Ntobeko, anything to add to that? Dr. Ntobeko Ntusi: I think I agree completely with Nkkil and I think this paper has a number of really important strengths, and I think those strengths and key contributions have to be taken in the context of one significant limitation and how we interpret these results. And that's the fact that when we normally see a patient in the clinic to diagnose hypertension, we would take two or three blood pressure measurements. In this study, they only took a single blood pressure measurement and that's the basis for the conclusions and for me a key limitation, but nonetheless, I think a very important contribution. Dr. Greg Hundley: Very nice. Well listeners, we want to thank Nikkil Sudharsanan from Heidelberg and Ntobeko Ntusi from Cape town for bringing us this important study, indicating that worldwide there's substantial variation really in the proportion of adults in need a blood pressure lowering medication, depending on which hypertension guideline is used. Well, let's move on now to our second feature discussion.   Dr. Greg Hundley: Listeners, we are now to our second feature discussion and we have with us Dr. Aloke Finn from the Cardiovascular Path Institute in Gaithersburg, Maryland and our content editor expert for pathology, Dr. Jeff Saffitz from Beth Israel Deaconess. Welcome gentlemen. Aloke, could you describe for us, what was the question you wanted to address with this researching? What was your study design and your study population? Dr. Aloke Finn: Great. Greg, thanks for your interest in our article and for highlighting it. We were really interested in understanding what the pathologic causes for cardiac injury were in people hospitalized with COVID-19, as you know, it's been reported in the literature that people with COVID-19 with cardiac injury do worse than those without cardiac injury, but the mechanism is not still well understood. So the study design was really based upon a collaboration with a group from Italy in the Lombardy region, where they had had a terrible outbreak in 2020, as you remember in February. And they had a number of hospitalized. People die from COVID-19 infection, and they too were interested in understanding the pathologic causes of chronic injury. We got IRB approval and those hearts were sent to us during the middle of this pandemic in the February, March time. And we were able to examine 40 of those hearts and report our pathologic findings. And these were unselected cases of hospitalized patients dying of COVID-19. Dr. Greg Hundley: That was great. And tell us a little bit what were your study results? Dr. Aloke Finn: So we, first of all, did an analysis based upon the presence of myocardial necrosis. So that was the sort of the selection factor, which hearts had myocardial necrosis which parts didn't have myocardial necrosis. We found that 35% of the hearts in this 40 cases had myocardial necrosis. Now, we divided those into the type or pattern of myocardial necrosis. Was it acute myocardial infarction? Was there a large area of infarction greater than one centimeter squared or was there focal myocardial necrosis less than one centimeter squared. It's small areas of focal myocardial necrosis. We've found that most cases of patients dying of COVID-19 with myocardial necrosis had focal myocyte necrosis. Not large areas but small areas of myocyte necrosis. And we looked for the cause of those necrosis, majority of those cases with focal myocyte necrosis had microthrombi as the cause of that necrosis. So that suggests the major mechanism of myocardial injury in COVID-19 patients is microthrombi. Dr. Greg Hundley: Very nice. Well, Jeff, let's turn to you. How do we put the results of this study in the context with perhaps other pathologic studies that have been obtained from hearts of individuals that succumb to COVID-19? Dr. Jeffrey Saffitz: It's a very important question. And I want to say that at the outset, there have been many papers published focused on the pathologic findings of COVID-19 patients who have come to autopsy. And I have to say that the quality of these papers has been quite variable. In many cases, the pathology being shown is actually post-mortem artifact. In other cases, the interpretation of the pathology is incorrect. And so I think we have to be very careful in a study like this to make sure that what is being reported is actually valid and meaningful in the context of the important clinical questions being posed. And in this case, I can say the pathology was really extremely impressive and very convincing. Dr. Jeffrey Saffitz: Another important aspect of this study has to do with the comparison of the composition of the microthrombi that were identified in patients dying from COVID-19 versus patients who have other types of coronary thrombosis, but in a different setting. And here, there were some interesting observations that provide insights, not only into mechanism of thrombosis, but also potential information about how one might want to target antithrombotic therapy in these patients. So I would really like to hear more from Dr. Finn on this interesting aspect of this study. Dr. Aloke Finn: Jeff, thanks for your comment and your question. I think I agree with you, this was another interesting aspect of the study. What was done was that were able to examine the constituents of thrombi, different types of thrombi both in the setting of patients who had COVID-19 and non COVID-19 STEMIs as well as microvascular thrombi described in the COVID-19 patients, as well as embolized thrombi that embolized a small microvascular within the heart. And what we essentially found was that these thrombi, that are COVID microthrombi are distinct in their constituents. Distinct in that they had more fibrin and more compliment activation than the other types of thrombi that we're studied. So I do think this begins to unravel the question about how are these thrombi forming and are they different from the type of thrombi we normally treat? And the answer is, yes. Dr. Greg Hundley: Very nice, Aloke. What study do you think needs to be performed next in this space? And after you, I'll ask Jeff the same question. Dr. Aloke Finn: Greg, I would like to know whether or not therapies like anticoagulant, anti-compliment, antiplatelet therapies can decrease the risk or the effect of the COVID-19 on myocardial injury. Is will we see a benefit to anticoagulant or antithrombotic strategies in the study? I think that is the natural next question to ask. Dr. Greg Hundley: Very nice. And Jeff, anything to add? Dr. Jeffrey Saffitz: Yeah, well, I'm an experimental pathologist, so I'm always interested in disease mechanisms. And I would like to understand more about how these microthrombi form, the role of endothelial cell injury, the role of cytokine storm and other factors which we know are contributing. I think in the end having a more fundamental understanding of these mechanisms will provide important insights, not only in trying to manage heart disease, but in fact, other organ system disease, which is likely being mediated by a similar mechanism in the kidney and potentially in the brain and other organs as well. So I think this is a great example about how autopsy can provide really critically important information in a new human disease and set the stage for subsequent studies that will really provide important dew information. Dr. Greg Hundley: Excellent. Well listeners, we want to thank Dr. Aloke Finn from Gaithersburg, Maryland, Dr. Jeff Savitz from Boston, Massachusetts for this excellent discussion and revealing the pathologic results of 40 hospitalized patients from Italy that expired after COVID-19 highlighting the cause of myocardial necrosis and how it was related to the presence of microthrombi. Dr. Greg Hundley: On behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the Run. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2021.  

Which apps should you recommend to your patients?On this episode of Quick Takes Dr. Gratzer sits down with returning guest and digital psychiatry expert, Dr. John Torous of Harvard University.They discuss the use of mobile apps to aid in diagnosis and treatment as well as issues around digital privacy, the potential of chatbots, and how AI may change the field. But at the heart of this episode, they try to determine just what makes a good app. What do physicians need to know before using an app in their clinical work?During Drs. Gratzer and Torous’ conversation we learn more about:  what makes a good app and how mobile apps can be integrated into mental health treatment how apps may pose a risk to data privacy and securitythe potential of chatbots and AIand the challenges of sustaining patient engagement with apps.  To hear more of what Dr. Torous has to say on the topic of digital mental health, listen to Quick Takes episode 3 What all physicians need to know about digital psychiatry.Follow us on Twitter

Dr. Chris Chen, MD, CEO of ChenMed, joins the CareTalk Podcast to discuss his experience with COVID-19, improving primary for seniors and more. About Dr. Chris Chen, MD: Dr. Christopher Chen is the CEO of ChenMed, a physician practice that aims to bring concierge-style medicine and better health outcomes to the neediest populations – low-income seniors managing multiple complex chronic conditions. Dr. Chen oversees ChenMed's operations through its senior medical centers throughout the southeastern United States and Chicago, as well as its portfolio affiliated primary care practices and groups. Raised in South Florida, home to ChenMed's headquarters, Dr. Chen graduated from the University of Miami's Honors Program in Medicine. Dr. Chen went on to complete his medical training at Beth Israel Deaconess, a major Harvard University teaching hospital in Boston, Massachusetts. His clinical skills and research accomplishments then led to a specialty position at Cornell University Medical College in Manhattan, New York, where he studied cardiology.Dr. Chen brought these valuable skills and experiences with him to ChenMed, where he has served as CEO since 2009. Under Dr. Chen's leadership, ChenMed has grown from four senior medical centers in Florida in 2010 to the 59 it operates in eight U.S. states today. ChenMed's innovative, physician-led model focuses on accountability and scalability, and the model has proven results. ChenMed patients have 33 percent fewer hospital days per year than the national average. As a fully capitated Medicare Advantage provider, ChenMed have succeeded in providing better care to patients at a lower cost by focusing on prevention, patient behavior modification, and practical solutions like increasing patient access to physicians and specialists and providing courtesy transportation, on-site imaging, and medication. Patient satisfaction is high, with Net Promoter Scores in the low-to-mid 90s.  Dr. Chen's guidance has led to accolades for ChenMed from numerous sources including the White House, the Department of Health and Human Services, the U.K. National Health System, and publications such as Health Affairs, Forbes® Magazine, and The Economist®. In addition, the company was named “Best Primary Care System in the U.S.” by Medical Economics. Dr. Chen and ChenMed have earned private working discussions with President Obama, key cabinet members, senators, and congressmen. Honors like these reflect ChenMed's innovative and compassionate approach to caring for seniors with complex diseases, as well as ChenMed's notable results in achieving better health care outcomes.Watch this episode on YouTube: https://youtu.be/FKDSB88edy4

Dr. Charles Christopher Smith is the Director of the Internal Medicine Residency Program, and Associate Vice Chair for Education at Beth Israel Deaconess Medical Center and Associate Professor of Medicine at Harvard Medical School. A graduate of the University Of Tennessee College Of Medicine, he completed his internal medicine residency training at Beth Israel Deaconess followed by a Chief Residency year. Dr. Smith completed the Rabkin Fellowship in Medical Education at Harvard Medical School and later served as the Director of the Fellowship. In addition to being the Program Director, Dr. Smith continues as Director of the Clinician Educator Track, has a busy primary care practice, teaches in many different venues, and has published on a variety of clinical and educational topics. Dr. Smith has been awarded the Alpha Omega Alpha, SGIM New England Medical Educator of the Year Award, the SGIM National Award for Scholarship in Medical Education, and the Robert C. Moellering Award for exceptional contributions as a clinician, teacher and researcher to name a few. A growth mindset, humility, and curiosity are the pillars of great mentees, says Dr. Smith. But even more important than that, is the environment that enables these kinds of mentees to flourish. Today, Dr. Smith teaches us what it means to create a positive learning climate. His strongest belief is that focusing on the positive—not the negative—is the best way to create an endless cycle of kindness, growth, and excellence within medicine. He makes it a practice to call out acts of kindness when he sees them (no matter how big or small), because it serves as positive reinforcement. And when it comes to feedback, he likes to point out the things he sees that are being done well—and correctly. And he reminds us: When we keep kindness at the forefront of our minds, we'll look at everything—and everyone—with more gratitude. Pearls of Wisdom: 1. Gratitude lies in the center of burnout. When we're feeling exhausted, reconnect with our patients to remember why we're here. 2. Kindness is in the small interactions we have every single day. When we see kindness, call it out. It will perpetuate the endless cycle of kindness, and it will build in yourself and others. 3. Say yes to opportunities early in your career. Build a team of mentors that help us lean into our discomfort, to try new things, and to realize our full potential.

This episode features Alexa Kimball, President and CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, Inc. Here, she discusses the biggest challenge she expects to face in the coming year, what she expects to see in artificial intelligence in the near future, and more. Thank you to our sponsor, Coverys. Copyrighted. Insurance products issued by Medical Professional Mutual Insurance Company and its subsidiaries. Boston, MA. In CA, transacting business as Coverys Insurance Company (CA# 6122-6).

This week we speak with Diane Hessan, a long-time, devoted member of the temple. Diane has done so many things for the congregation. She’s been on the board, starred in famous temple musicals, helped in the preschool (both of her daughters are graduates of our program and went on to become b’not mitzvah here), and even served on the last rabbinic search committee.She has a few other things going on. Diane’s accomplishments are spectacular. She was the founder and CEO of C Space for 14 years, working with hundreds of global brands to gain insight and inspiration from their consumers. Since then she’s led other companies, written books, been invited to serve as a trustee on several boards including Tufts University and Beth Israel Deaconess, and recognized for her business acumen and her leadership by several prestigious organizations. And… there’s more.The focus of our conversation will be another one of Diane’s passions: listening to how and why people vote the way they do. For almost five years, week after week, Diane has personally interviewed a panel of voters from all states, ages and ends of the political spectrum. She looks for trends, shifts, and common ground, and then writes about her findings in the Boston Globe. With the election just days away, her insight could not be more timely. To read more about Diane click here. To read her Op-Eds in the Boston Globe click here.

Alex Forsyth and Dr. Sarah Carlson Discuss Acute Limb Ischemia.  Alex Forsyth is a 4th year medical student at Boston University She’s a cofounder of the Vascular surgery student interest group and is exciting to be applying to Integrated Vascular surgery programs this season Dr.  Sarah Carlson is an assistant Professor of Vascular Surgery at Boston University where she practices at the Boston VA Medical Center.  She completed her general surgery training at Beth Israel Deaconess in Boston followed by a fellowship in Vascular Surgery at Dartmouth-Hitchcock Medical center in new Hampshire.

In this episode of Fireside Chat, with Kevin Tabb, M.D., President and CEO, Beth Israel Lahey Health to discuss the merger between Beth Israel Deaconess and Lahey, the impact that COVID has had on telehealth services, and the characteristics of a leader during a crisis.

Community hospitals across the country are in the process of reopening services and operations closed as COVID-19 started to spread across the country. Rich Fernandez, president, Beth Israel Deaconess Hospital - Milton in Massachusetts, one of the states hit hardest by the COVID-19 virus, walks us through the hospital's reopening strategy and discusses the steps taken to adjust to the new normal while also ensuring the safety of staff, patients and visitors. Rich touches on all aspects of the reopening from workforce management changes to the implementation of new patient waiting room procedures and everything in- between. He also shares some of the things he was most surprised about during the crisis and what the hospital is doing to prepare for a potential virus surge in the Fall.

In episode #4 of the HP population health series, we interview Dr. Jacques Kpodonu and hear his insights on the use of advanced technologies like artificial intelligence and robotic surgery to provide better access and population health. He shares some great personal and professional stories as well as anecdotes to help advance your population health efforts. We enjoyed our visit with Dr. Kpodonu and hope you will too! About Dr. Kpodonu Dr. Jacques Kpodonu is a cardiovascular surgeon specializing in global health system innovation with an emphasis on addressing rheumatic heart disease. Currently a faculty member at Harvard Medical School and an adjunct Professor of Surgery at the University of Ghana. Dr. Kpodonu’s interests lie in biomedical discoveries, modernizing the operating room via novel design and growing the global capacity of cardiac surgeons especially in emerging countries with his work in global cardiac surgery. In addition to writing medical textbooks and his research work Dr. Kpodonu is a key opinion leader in the design of advanced hybrid cardiac surgical rooms and biomedical innovation and is passionate in advocating for the use of telehealth services- especially in African nations .Dr. Kpodonu is frequently quoted in the Orange County Register, American Health Journal, and holds leadership positions with the Society Thoracic Surgeons and the American College of Cardiology. Based in Boston, he sits on the diversity and inclusion committee for the American College of Cardiology and the Society of Thoracic Surgery and has helped to raise millions of dollars to finance the construction of advanced robotic hybrid operating room both here in the USA and in Africa. In this podcast you will learn: How robotics and A.I. can add value to population health efforts. What providers and health systems can do to leverage technology, together, to advance patient care. Why it is critical to give serious thought to advanced technologies in the strategy and implementation of population health strategies. Valuable Links: Listen to the other episodes on HP Population Health Series: https://outcomesrocket.health/hppophealth/ For more about HP Population Health IT Solutions visit: https://www8.hp.com/us/en/solutions/healthcare/population-health.html

Dr Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr Greg Hundley: I'm Greg Hundley, associate editor from the VCU Pauley Heart Center in Richmond, Virginia. Dr Carolyn Lam: Greg, amyloid cardiomyopathy is the rage. I cannot tell you the number of discussions I've had on the topic. Of course, it was tafamidis, the amazing results with that trial that really made us realize we need to pick this up. But have you ever thought about the cost effectiveness of tafamidis for amyloid cardiomyopathy? Well, guess what? We're going to have a whole feature discussion just about that. But first let's go to our summary, shall we? Dr Greg Hundley: You bet, Carolyn. Well, let me get started. I'm going to talk about regulation of cell cycle growth as well as division in regard to cardiac regeneration. My first paper comes from Dr Lior Zangi from the Mount Sinai School of Medicine. Well, Carolyn, have you ever wondered why the adult mammalian heart has limited regenerative capacity? Dr Carolyn Lam: All the time, Greg. Dr Greg Hundley: Well, of course you have. It's mostly due to postnatal cardiomyocyte cell cycle arrest. In this study the investigators evaluated the effect of pyruvate kinase muscle isozyme 2 and cardiomyocytes through models of loss, that is cardiomyocyte specific PKM2 deletion during cardiac development or gain using cardiomyocytes specific PKM to modified mRNA to evaluate PKM to function and regenerative effects post-acute or chronic MI in mice. Dr Carolyn Lam: Nicely described. What did they find, Greg? Dr Greg Hundley: What they found is that PKM2 is expressed in cardiomyocytes during development and immediately after birth, but not during adulthood. Using cardiomyocytes PKM to modified RNA, they found that cardiomyocyte targeted strategy following acute or chronic MI resulted in increased cardiomyocyte cell division, enhanced cardiac function, and improved long-term survival. They found that PKM2 regulates the cardiomyocyte cell cycle and reduces oxidative stress damage through anabolic pathways and beta-catenin. Dr Carolyn Lam: Cool, Greg. Man, this cardiac regeneration really, really is a hot area. Dr Greg Hundley: Carolyn, that is so insightful because these results really impact research toward unlocking pathways that could be involved in induction of myocyte cell division and regeneration in those sustaining MI or conditions like MI. Dr Carolyn Lam: Nice. Well, Greg, I'm going to change tones here and ask you, can we prevent atrial fibrillation with treatments for diabetes? Well, guess what? We have a paper next. It's from Dr Wiviott from the TIMI Study Group and his colleagues who really reason that since atrial fibrillation is associated with hypertension, obesity and heart failure in patients with diabetes and SGLT2 inhibitors have been shown to lower blood pressure, reduce weight, and reduce hospitalization for heart failure in these patients, perhaps SGLT2 inhibitors may also reduce the risk of atrial fibrillation. They explored the effect of Dapagliflozin on the first and total number of atrial fibrillation and atrial flutter events in patients from the DECLARE-TIMI 58. As a reminder, they had type two diabetes with either multiple risk factors for or known atherosclerotic cardiovascular disease. Now importantly, atrial fibrillation events were identified by a search of the safety database using these MedDAR preferred terms. Now what they found was Dapagliflozin reduced the risk of atrial fibrillation events during follow-up as well as the total number of atrial fibrillation events in patients with type two diabetes. These reductions were consistent across major subgroups including sex, presence of atherosclerotic cardiovascular disease, history of atrial fibrillation, history of heart failure, history of ischemic stroke, HBA1C groups, body mass index groups, blood pressure or EGFR. They looked at all these subgroups because these are all clinical factors, well established, with associations with the risk of atrial fibrillation. Dr Greg Hundley: Wow, Carolyn. Another sort of feather in the cap for the SGLT2 inhibitors. What does this mean for clinical practice? Dr Carolyn Lam: Ah. I'm not going to answer it here. I am going to say everybody has to read the excellent editorial by Dr Granger from Duke University and Dr Mahaffey from Stanford University School of Medicine. But what I will tell you is their concluding sentences. They said, "This report provides evidence that Dapagliflozin appears to reduce atrial fibrillation events in patients with diabetes and coronary disease and multiple risk factors. It also raises the issue of how to determine when effects on a secondary outcome, particularly one collected without the rigor of systematic collection using perspective definitions and case report forms, whether or not these are reliable." So must read. Dr Greg Hundley: Absolutely. Carolyn, my next study comes and evaluates arrhythmogenic right ventricular cardiomyopathy and is really investigating the concept of auto immunity, looking at associations of circulating anti heart and anti intercalated disc auto antibodies with disease severity and family history. The paper comes from Professor Alida Caforio from the University of Padova. Again, looking at the role of auto antibodies in patients with ARVC. An interesting topic. Dr Carolyn Lam: Yeah, that's really novel. What did they find? Dr Greg Hundley: They investigated ARVC pro bands, so those that sort of started with the disease process in a family and noted an increased frequency of serum organ specific anti heart autoantibodies and anti-intercalated disc autoantibodies in a sizeable arrhythmogenic RVC cohort as compared to controls. They found that positive AHA status. Dr Carolyn Lam: Anti-heart antibodies. Dr Greg Hundley: Yep. Was associated with lower left ventricular ejection fraction, a higher frequency of cardiac symptoms and implantable cardioverter defibrillator implantation. Positive AIDA was associated with lower ejection fractions in both the right and the left ventricle. Dr Carolyn Lam: AIDA being the anti-intercalated disc auto antibodies. Wow. That is interesting. But what are the clinical implications? Dr Greg Hundley: Well, the presence of both these organ specific AHA and AIDA antibodies provides evidence of autoimmunity in the majority, so 85% of familiar, and almost half, 45%, of sporadic ARVC. In programs and in effective relatives, these antibodies were associated with the disease severity features. So really a link with this auto immunity and ARVC. Dr Carolyn Lam: Yeah. I never thought of ARVC as an autoimmune disease. Very interesting. But let me also tell you what else is in this week's issue. There are letters to the editors, one from Dr Kaski regarding the mag STEMI randomized control trial questioning whether improving coronary vasal motion can be equated to restoring patient's cardiovascular health. Interestingly with a letter in response from Dr Sabatine. There's also a research letter by Dr Alahmad on the cardiovascular mortality and exposure to heat in an inherently hot region and where they were was Kuwait. They also drew some implications for climate change. Very interesting piece. There's also an ECG challenged by Dr Verma describing conduction abnormalities and ischemic cardiomyopathy in an 84-year-old man. Dr Greg Hundley: Very nice. Carolyn, in the mailbag, there's a nice research letter from Dr Nicholas Leeper from Stanford University School of Medicine. It's entitled “The 9p21 locus promotes calcific atherosclerosis.” Our own Josh Beckman has an on my mind piece regarding “The Big Mac Attack on Peripheral Arterial Disease.” Dr Carolyn Lam: I love that. I just love the titles Josh comes up with. Dr Greg Hundley: Then finally Bridget Kuehn has a very nice sort of correspondence on Cardiovascular News regarding cardiac imaging on the cusp of artificial intelligence. What a revolution we have ahead, Carolyn, and I know that's a topic that's true to your heart. Dr Carolyn Lam: It is. I loved her paper. Dr Greg Hundley: Okay. Carolyn, how about we get onto that feature article? I'm waiting to hear about the cost effectiveness of tafamidis. Dr Carolyn Lam: Me too. Dr Greg Hundley: Well listeners, we have got a great discussion for our feature publication today and we have Dr Dhruv Kazi from Beth Israel Deaconess in Boston and our own associate editor, Dr Justin Ezekowitz from University of Alberta. Well, as we get started, Kazi, can you tell us a little bit what was the hypothesis that you wanted to test with this study and maybe even before that a little bit of background with transthyretin amyloid and tafamidis? Dr Dhruv Kazi: Yeah. Transthyretin amyloidosis is a subgroup of patients who present with heart failure with preserved ejection fraction, which we know is a heterogeneous condition that has been pretty resilient to effective guideline directed therapies over the past decade. It's a subgroup of patients generally presenting in their 70s with slowly declining quality of life and a median survival of about three years. It hadn't had an effective therapy before and so when tafamidis, which is a stabilizer of transthyretin and prevents its deposition in the myocardium, was developed and tested in a randomized clinical trial that showed an improvement in survival, a reduction in heart failure hospitalizations and a slowing of decline and quality of life. It was viewed as a really big win for the heart failure community. What came as a surprise though is the pricing. It was launched in 2019 at $225,000 a year. We set out to ask, given that this is a severe disease without alternative treatments, is this price tag generating enough value? Is this a cost-effective therapy? The background here again is that oncologic therapies have had a long history of very high prices for rare diseases and severe diseases. But this is the first time we're seeing this in cardiology. Can we think more broadly about how we're going to tackle this issue? Not just for tafamidis but also for other drugs that come down the pipe. Dr Greg Hundley: Wow. $225,000 per year. Tell us what was your study design, and how did you go about evaluating this issue? Dr Dhruv Kazi: We started off with the one phase three trial of the drug that has been published and simulated in a mathematical model the population that would be eligible for this therapy, reproduced the events, heart failure hospitalizations, debts, quality of life that were seen in the trial for the first three years, and then extrapolated beyond the trial based on what we know about HFpEF and what we know about transthyretin amyloidosis. It's a mathematical model that first reproduces what was seen in the trial and then extrapolates beyond what we think is the best guess of what happens to these patients. We tested a variety of scenarios whether the drug continues to be effective, whether the effectiveness declines over time or the effectiveness ceases immediately after three years. Dr Greg Hundley: What did you find? Dr Dhruv Kazi: What we found was interesting and it surprised us a little bit, which is that in the base case, which is assuming that the drug stays effective beyond three years, the drug is actually very effective in the traditional sense. It added 1.3 quality adjusted life years. For context here, this is about twice the effect size you expect to see with Entresto, and the HFpEF patients. So here's a drug that we've accepted and HFpEF has part of guideline directed medical therapy. Tafamidis in that best-case scenario is about twice as effective, but it is not cost effective. Because you're paying $225,000 for every year that the patient is on the medication, its incremental cost effectiveness ratio compared with usual care was $880,000, so well above what we would consider value for money. That's the best-case scenario assuming that the drug is permanently effective, if the drug's effect wanes over time, which is very likely as these patients get older and sicker, then the drug gets even less economically attractive. Dr Greg Hundley: You've pointed out in your article, if you had 120,000 transthyretin patients in the United States, that would translate to how many dollars? Dr Dhruv Kazi: We estimate that if all of those 120,000 patients received tafamidis, the healthcare spending would go up by $32 billion a year and most of it is towards the drug. But the caveat is that we think 120,000 patients in the US is a very conservative number because the diagnostic technology for amyloid cardiomyopathy has improved substantially over the last five years so that we no longer need biopsies. We can use nuclear scans to diagnose the disease and we have pretty good to genetic testing to identify the genetic variant of the disease. We think that number is probably closer to 200,000 or even higher because the healthcare expenditure is almost entirely driven by drug costs. The more patients we diagnosed, the bigger the budget's impact on healthcare spending. Dr Greg Hundley: Oh my. Well Justin, for our listeners, Justin resides in Canada. Justin, what do we do with these results? I mean this is quite a sticker shock for probably an important therapy for this patient population. Dr Justin Ezekowitz: Greg, it's a great issue and Kazi, thank you very much for this terrific, easily understandable manuscript that I think everybody should read as it's very well written and easy to understand for us non-health economists. The sticker shock is a bit of a tricky one because we always want to do what's best for our patients. When we look at that budget impact analysis, the challenge is what do we think internationally? The US is critical in terms of understanding this, but then for the rest of the world, there's certainly almost no willingness to pay at this threshold and with an uncertain incidence of amyloidosis globally, but also within the US and Canada and the difficult in diagnosis already, I think we're going to have to realize what can we do for our patients and who benefits the most with this drug given its importance and its efficacy? Kazi, you mentioned another thing which I think is critical is what happens after 30 months if the effect wanes and where does that take us for the impact on cost and effectiveness over time but also the budget impact analysis? Because the second drug or third drug may very well come along that may fill that niche. Dr Dhruv Kazi: Justin, that's a really good question. I mean the study only goes to 30 months and that's the only one randomized trial for tafamidis that we're working off of. So there's substantial uncertainty about what happens to this drug beyond 30 months. It's reasonable to assume that some of the effect persists, that as patients get older, get sicker, that effectiveness will wane over time. Which ties very closely to the cost effectiveness. So if the patients continue to take the drug but it's not as effective as you can imagine, it becomes less cost effective. This also has implications for other drugs coming down the pike, which may or may not be more effective than tafamidis. They may or may not be tested head to head with tafamidis. Physicians are going to be left with the question, very clinically relevant question, of which drug to start with, how do you switch on them the next generation or more expensive drugs that come down the pike? We'll have to rely on both real-world evidence and to some extent mathematical modeling to use our best judgment on developing a treatment strategy for these patients. But rest assured that our current regulatory framework means that the drugs coming down in the future will be more expensive than tafamidis and hence, this is a good time to have the conversation about cost effectiveness and our willingness to pay for innovation. Dr Greg Hundley: What needs to happen next to help either lower cost or develop some sort of competition in the treatment of this disease to lower the cost? Dr Dhruv Kazi: I can take a stab at that. Greg, I think the findings of this particular drug in transthyretin amyloidosis is illustrative of the challenges that lie ahead. I think there are clinical research and policy implications. As clinicians, it's really important for us to know that this high cost of the drug is not a theoretical challenge. It's a practical challenge for our patients. The majority of these patients are going to be on Medicare part D. We estimate that the out of pocket costs is going to be in the range of $8,000 to $9,000 a year even with Medicare part D, which is a big amount of money for our fixed income seniors. I encourage our clinicians to have this conversation about out-of-pocket costs with patients, not just when you start the therapy but throughout the year. We know that the Medicare part D copays change over the course of the year based on where they are in the insurance plan. Having this conversation may help preclude costs related non-adherence. We might be able to identify patients early or at risk, put them into patient support programs or switch them to alternate therapies that may not be as effective but at least are likely to offer the patient some support. From a research perspective, we really need to figure out what subgroup of patients are more likely to benefit. Let's say we have 200,000 patients with transthyretin amyloidosis in the US. We need more research, and the company is not going to be vested in doing this research, it's going to have to be NIH funded research to identify subgroups of patients who benefit most from this drug, both in the short term and over the long term. From a policy perspective, what this drug pricing issue is telling us is that we provided incentives for companies to innovate in the rare disease orphan drug program. These incentives are working. More than half of the drugs that are coming out now or have in the past year are under this rare disease umbrella. But these drugs, once they're approved, are super expensive. We need to figure out a regulatory framework where we continue to incentivize innovation for rare diseases for orphan drugs, but at the same time tie those incentives to the final pricing to ensure that the patients get access to the drug and not just the wealthy patients who can afford the copays, but all patients who would benefit from the drug. One of the things that comes to mind as clinicians and researchers is that particularly in cardiology, we are obsessed with innovating, with regards to new molecules and new technology. I would like us as a community to focus not just on molecules but also on markets because the innovation is not meaningful if our patients cannot have access to them. This year being the presidential election year, we're going to hear a lot about drug pricing. What I hope that this example shines a light on is that drug pricing is complicated and trying to figure out the right framework to incentivize innovation while it's still ensuring access is going to take thoughtful interventions, regulatory interventions, and clinicians should very much be a part of that process. Dr Greg Hundley: Well listeners, we've heard a wonderful discussion here highlighting a new therapy for a disease process that's being increasingly diagnosed with our aging population and new technologies, magnetic resonance, echocardiography that identify this condition. But then how are we going to afford some of the therapies that are moving forward and design a system that emphasizes not only scientific discovery, but cost effectiveness? We want to thank Dr Dhruv Kazi from Beth Israel Deaconess and also Justin Ezekowitz from the University of Alberta. We hope you have a great week and look forward to speaking with you next week. This program is copyright the American Heart Association 2020.

Today, we have two special guests with us to talk about this wonderful topic. Dr. Margie Thorsen is a PGY-1 at Brown/Women and Infants Ob/Gyn residency and Dr. Emily Seidler from Beth Israel Deaconess to talk about treatment of infertility. Twitter: @creogsovercoff1  Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

Today we sat down with Dr. Emily Seidler from Beth Israel Deaconess to talk about treatment of infertility. If you have ever had issues remember all the different types of treatments, come listen to this episode!  Twitter: @creogsovercoff1  Instagram: @creogsovercoffee Facebook: www.facebook.com/creogsovercoffee Website: www.creogsovercoffee.com Patreon: www.patreon.com/creogsovercoffee You can find the OBG Project at: www.obgproject.com

In this next episode of Thrive Bites, I chat with Dr. Heather about integrative ways to curb emotional eating and weight loss on this exciting episode!Heather Hammerstedt, MD, MPH is a double board-certified emergency physician and lifestyle medicine physician. She is CEO of Wholist, where she uses her background in Integrative Nutrition, health coaching and culinary medicine to integrate the evidence behind weight, sleep, food, exercise, mindfulness and more to help empower and implement sustainable lifestyle transformation in 12 week coaching programs specifically for women finally ready to crush emotional eating and weight issues for the final time. She completed her medical studies at Temple University School of Medicine and did her postgraduate residency in Emergency Medicine at Beth Israel Deaconess’s Harvard Affiliated Emergency Medicine Residency program. She also holds a Masters of Public Health degree from Harvard School of Public Health, with a concentration in international health sector development and nutrition. She is one of the co-founders and executives of the nonprofit 501c3 organization, Global Emergency Care (GEC) She loves life in Idaho with her husband, skiing, rafting, running, and chasing after two small boys and two big chocolate labs.Social Media Links:Website: www.wholisthealth.comPodcast: https://podcasts.apple.com/us/podcast/curate-your-health/id1478410990Instagram: www.instagram.com/wholisthealthFacebook: www.facebook.com/wholisthealthPlease support this podcast to impact others to live better: https://patron.podbean.com/thrivebitespodcast*Interview views are opinions of the individual. This podcast is not a source of medical advice*Copyright © 2020 by TheChefDoc, LLCAll text, graphics, audio files, Java applets and scripts, downloadable software, and other works on this web site are the copyrighted works of TheChefDoc, LLC. All Rights Reserved. Any unauthorized redistribution or reproduction of any copyrighted materials on this web site is strictly prohibited.

Join Ruth Clark, RD, LD, MPH as she shares great tips on how you CAN control your hormones, your weight, skin, and how you feel and look, just by learning how to control inflammation in your body. What you will learn:What you put in your mouth is just as important or even more important than what you put on your skin. To have beautiful skin you need to create a healthy foundation.Inflammation is the root cause of most diseases that we suffer from in Western society. We have profound control over the amount of inflammation that gets created in our bodies.Inflammatory skin conditions such as psoriasis, eczema, rosacea and just rashy skin issues are the number one reason for a visit to the dermatologist.What is inflammation? Why does it affect skin?How inflammation ages the skinThe role of free radical damage. What can you do about it?Specific nutrients and foods that contain them.The role of nutrition in acne.The role of waterSleep and Stress, and its role in inflammation. About Ruth:Ruth Clark is a Registered Dietitian and Functional Nutritionist with a B.S. in Human Nutrition, a master’s degree in Public Health from Boston University and over 35+ years of experience in the health care field. She has held positions at both Harvard and Tufts teaching hospitals, corporate America, and was formerly Executive Director of Wellness Programming for Beth Israel-Deaconess hospital in Boston. For the past 25 years, Ruth has specialized in helping mid-life women who are struggling with weight, fatigue and mood to create more vitality in their lives. She is a best-selling author of Cool the Fire: Curb Inflammation and Balance Hormones. The book includes 10 High Impact Nutritional Strategies, over 150 delicious, healthy and healing recipes which integrate into 28 days of Mindful Menus. She is a nationally known nutrition speaker, a former member of the Scientific Advisory Board for several nutrition related companies, has authored several articles in medical journals and the lay press and has produced a series of nationally distributed CD’s on nutrition supplementation. She is also certified by the Mind-Body Institute of Boston. How to reach Ruth:Email Ruth@RuthRD.comWebsite www.smartnutritionllc.comAttend Ruth's FREE Webinar:www.Reset.RuthRD.comSupport the show (https://podcasts.apple.com/us/podcast/beauty-call-podcast/id1462542236)

Dr. Kevin Tabb fell into medicine through his training as a medic in the Israel Defense Forces, and after medical school and a five year residency, he soon entered the world of healthcare IT. As president & CEO of the newly-formed Beth Israel Lahey Health system, this diverse background gives him a unique perspective to navigate the constantly-changing healthcare landscape where technology continues to play an increasing role.Dr. Tabb now has a prominent position in the greater Boston area’s storied history of driving healthcare innovation. He’s leading the region’s second-largest health system – including 4,000 physicians and 35,000 employees across academic medical centers, community, and specialty hospitals – formed by the March 2019 merger of the Beth Israel Deaconess and Lahey Health systems, along with Anna Jaques, Mount Auburn and New England Baptist Hospitals.Creating a single and cohesive point of care will be one of the most important attributes of a successful health system in the future, according to Dr. Tabb. The dynamics of delivering on this promise are especially acute as health systems across the country merge, and it’s a key focus at Beth Israel Lahey Health.During this episode of Healthcare Is Hard, recorded live on stage at the Digital Health Innovation Summit, Dr. Tabb talks to Keith Figlioli about a number of issues critical to delivering on his vision for a successful, modern health system, including:The Build vs. Buy Debate. When it comes to partnerships with new entrants in the healthcare market, new technologies, or other aspects of running a next gen health system, working with third-parties and bringing everything together makes it more difficult to create a cohesive organization. That’s why Dr. Tabb’s preference is to explore internal development first, a luxury large and growing health systems are more likely to have the resources to accomplish. But he recognizes the reality, knowing when and how to investigate if a third party brings something unique that would be too complex to develop in-house.Solutions Looking for Problems. With a background in health IT, Dr. Tabb is approached almost daily by various companies and investors and says the majority of what he sees comes from people offering niche solutions to small problems. Unless a solution is focused on the larger challenges associated with helping the different aspects of a health system come together and operate more cohesively, he’s much less likely to be interested.Evolving Access Points for Care. The way people access care is rapidly changing. Dr. Tabb compares this shift to the emergence of digital photos and Kodak’s failure to adapt because revenues from film and chemicals weren’t impacted at first. Kodak failed to realize soon enough that pictures can be made in many different ways. And to avoid a similar fate, traditional health systems need to quickly recognize the many different ways and different places care can and should be delivered. They need to adapt and deliver the seamless and unified experience that patients are starting to demand.Differences Between the U.S. and Europe. As someone who grew up in California, but served in the military, went to medical school, and did his residency in Israel, Dr. Tabb is frequently asked for his opinion on the biggest differences between U.S. and European healthcare. He points to the lack of a single system of care, and talks about how critical it is to figure out a new approach so people don’t fall through the cracks – especially when they’re sick and most vulnerable.To hear Dr. Tabb talk about these topics and more, listen to this episode of Healthcare is Hard: A Podcast for Insiders.

近日，Beth Israel Deaconess医学中心的研究人员指出了肿瘤细胞中PTEN活化降低的元凶之一——E3泛素连接酶（WWP1），同时他们发现，西兰花中的吲哚-3-甲醇（I3C）竟然可以有效恢复PTEN活性，进而遏制癌症发生发展！

“We need to be part of the solution to support the lower cost of care”

Starting an Overseas Health Non-Profit with Heather Hammerstedt, MD How do you start an Emergency Medicine program in a region without emergency rooms? How do you start an overseas non-profit? Heather explains how she and a few friends helped a rural community in Uganda start the non-profit Global Emergency Care. That then grew into an entire program for training nurses and other healthcare providers to run the unit. It's truly amazing how helping a community solve one small problem then grew into a larger and larger service. Learn how you can volunteer in Uganda for this amazing program as well! Stick around to the end of the episode, because Heather tells us all about her new side hustle: Wholist Health!  In this episode, you will learn: The humble beginnings of a non-profit organization Developing a curriculum for emergency care practitioner program How Dr. Hammerstedt is teaching herself out of her job Implementing emergency medicine and care programs in Africa Issues along the way in implementing the program People to include in making the program possible How to Volunteer for the program Heather Hammerstedt, MD, MPH is a board-certified emergency physician in Boise Idaho and did her postgraduate residency in Emergency Medicine at Beth Israel Deaconess's Harvard Affiliated Emergency Medicine Residency program. She is also one of the founders of the nonprofit 501c3 organization, Global Emergency Care (GEC) and currently functions as Executive Director. GEC currently has an ongoing clinical, academic, and consultant relationship with stakeholders in Uganda, where they have created the country's first emergency medicine training programs for advanced providers and physicians and are working with the national government to create a national emergency care system. If you want to know more about the nonprofit, you may visit their website. You may also get to know Heather Hammerstedt MD MPH by clicking on this link. You may also send her an email at heather@globalemergencycare.org. If you also want to know more about Heather Hammerstedt MD's Wholist Health, you may visit this site or send her an email at heather@wholisthealth.com.   Thank you for listening to the Hippocratic Hustle! I know that time is your most valuable resource so I really appreciate you spending some of it with me. If you enjoyed today's show, please share it! If you'd like to help me improve and grow the podcast, send your suggestions to: Carrie@HippocraticHustle.com Lastly, don't forget to subscribe to the podcast, so you won't miss an episode!

As health IT has evolved, so has the role of the CIO. Today, a health care organization’s chief information officer must be prepared to meet changing organizational, clinical and population health-related demands with increasingly capable and innovative technology. Less than a decade ago, 9 out of every 10 physicians in the U.S. updated their patients’ health records on paper charts. In part thanks to the introduction of meaningful use in 2009, electronic health record (EHR) systems have been widely adopted and have transformed health care – and by the end of 2017, approximately 90 percent of physicians across the country were using EHRs. With EHR adoption came the influx of big data, there have come questions around data access rights and a heightened need for interoperability. These concerns and more sit at the feet of the modern CIO. In this episode of The Cerner Podcast, we’re joined by Dr. John Halamka, the CIO and the CMIO at Beth Israel Deaconess Medical Center. Dr. Halamka joined Beth Israel Deaconess in 1998 as the Chief Medical Information Officer, and today is responsible for the IT strategy, security and operations there. In this episode, he discusses some of the top issues CIOs and CMIOs are facing in today’s marketplace.

In the first new episode of 2018, we are talking with Amy Patel, MD, a breast imager at Beth Israel Deaconess and Rob Mackey, MD, a radiologist at Doctor’s Imaging Group in Gainesville Florida.  In this episode, we discuss what these two doctors wish they had known as they were entering residency, as residents and as they were first entering practice.  Dr. Patel provides great insights from the perspective of a radiologist in an academic institution, while Dr. Mackey provides insights from a private practice perspective.  This episode covers great topics such as how to prepare for a radiology residency, what opportunities should residents be aware of to take advantage of, tips for managing time, money and relationships, and even advice on things like supplemental insurance.    

In this episode, Nicole Kupchik, MN, RN, interviews Bridgid Joseph, Clinical Nurse Specialist and Program Director for the Emergency Cardiovascular Care Center at Beth Israel Deaconess Medical Center in Boston. Bridgid shares how her medical center tackled the challenge of implementing the latest American Heart Association ACLS and BLS guidelines in an organization with multiple campuses, satellite campuses, and more than 3,000 team members.

We are all patients, but only one has come to be recognized as the face and voice for a growing community of activists encouraging the rise of participatory medicine. My guest today is a cancer survivor and patient advocate, Dave deBronkart, better known as e-Patient Dave. The evolving field of health & medicine has many challenges, but having patients pro-actively participate in their medical decision-making shouldn’t be one of them. As an industry that has historically relied on the one-sided expertise of physicians, technology and the internet have fundamentally changed the game. Patients have much greater access to information than ever before. So why then is it still so difficult to get patients to take charge of their health?  As it turns out, e-Patient Dave believes there is a science to patient engagement and behavior change that is not too different from how we describe the mechanism of action of a drug. On this episode, Dave shares what this means, what he has learned in his own personal journey on battling the ugly “C” word, what he believes is the fundamental difference between a patient and consumer, and what we need to do going forward so that patients play a more central and active role in their care. I found this conversation to be both inspirational and informative as I hope you will too. e-Patient Dave is an inspiring human being who believes the voice of the patient needs to be heard around the world. All this and more on today’s episode. Now, That’s Unusual. About “e-Patient” Dave deBronkart Dave deBronkart, better known as e-Patient Dave, was diagnosed with Stage IV kidney cancer in January of 2007. The best information gave him just 24 weeks to live, and with tumors in both lungs, several bones and muscle tissue, the prognosis was grim. Lucky enough to be connected with an academic medical center, Boston’s Beth Israel Deaconess, he received superior care that leveraged the best available research. Once it was clear that he had beaten the disease, deBronkart became an activist, seeking to open the healthcare information system directly to patients on an unprecedented level, thus creating a new dynamic in how information is delivered, accessed and used by the patient. Dave is the author of the highly rated Let Patients Help: A Patient Engagement Handbook and one of the world’s leading advocates for patient engagement. After beating stage IV kidney cancer in 2007 he became a blogger, health policy advisor and international keynote speaker. He is today the best-known spokesman for the patient engagement movement, attending over 500 conferences and policy meetings in fifteen countries, including testifying in Washington for patient access to the medical record under Meaningful Use. A co-founder and chair emeritus of the Society for Participatory Medicine, e-Patient Dave has appeared in Time, U.S. News, USA Today, Wired, MIT Technology Review, and the HealthLeaders cover story “Patient of the Future.” His writings have been published in the British Medical Journal, the Society for General Internal Medicine Forum, iHealthBeat, and the conference journal of the American Society for Clinical Oncology. In 2009 HealthLeaders named him and his doctor to their annual list of “20 People Who Make Healthcare Better,” and he’s appeared on the cover of Healthcare IT News and the Australian GP magazine Good Practice. Key Interview Takeaways The ‘e’ in e-patient stands for more than just ‘electronic.’ An e-patient is equipped, engaged, empowered and enabled to ask, “How can I help?” When considering scientific literature, ask yourself, “Was this study done well?” e-Patient Dave has a great respect for the literature, but he understands that it can be unreliable. Doctors are not trained how to examine and validate clinical studies, thus patients aren’t always receiving care based on the latest information. Though we crave certainty, we live in uncertainty. Our body has just twelve ways to express a problem,

Immunotherapy combinations are just beginning. At the ASH 2015 conference Dr. David Avigan, MD of the Beth Israel Deaconess Medical Center shared his work to use a vaccine with an additional immunotherapy (a PD-1 blocker) and autologous transplant to make the transplant more durable and eliminate minimal residual disease. Learn more about this dendritic cell vaccine, how it works and why the road to immunotherapy will leverage the best available treatments for the best ultimate outcomes.  Thanks to our episode sponsor, Takeda Oncology.

Program tests whether giving patients access to doctor’s notes can improve safety and adherence to plans.

On the Wednesday, April 9th broadcast at 10AM PT/1PM ET our special guest is Danny Sands, MD, Health IT Consultant at Zev Enterprises and Co-Chairman, Co-Founder, and Past-President at Society for Participatory Medicine. 'Danny Sands is passionate about healthcare transformation, non-visit based care, collaboration in healthcare, and participatory medicine. He spent six years at Cisco, most recently as chief medical informatics officer, where he provided both internal and external health IT leadership and helped key customers with business and clinical transformation using IT. Danny's prior position was chief medical officer for Zix Corporation, a leader in secure e-mail and e-prescribing, and before that he spent 13 years at Beth Israel Deaconess Medical Center in Boston, where he developed and implemented numerous systems to improve clinical care delivery and patient engagement. He has earned degrees from Brown University, Ohio State University, Harvard School of Public Health, and trained at Boston City Hospital and Boston's Beth Israel Hospital. Dr. Sands currently holds an academic appointment at Harvard Medical School and maintains a primary care practice in which he makes extensive use of health IT (much of which he helped to introduce during his tenure at Beth Israel Deaconess). Sands is the recipient of numerous health IT awards, has been elected to fellowship in both the American College of Physicians and the American College of Medical Informatics, and is a founder and co-chair of the board of the Society for Participatory Medicine.' Dr Sands co-authored 'Let Patients Help' with ePatient Dave. Join is for an informative session.

Facing a $100+ million financial meltdown in 2002, The Beth Israel Deaconess Center called on Paul Levy to step in as CEO. Although Paul was new to healthcare, his effective leadership transformed the hospital into one of the best in the Northeast.