Smiling Off The Charts

Few can deny that conversations about patient satisfaction are continuing to grow and intensify. More and more leading providers are stressing a needed shift in attitude from treating patient care as a transaction toward acknowledging it as a participatory experience. Fortunately, one notable surgeon is leading the charge.

In an industry where only 251 out of more than 3,500 U.S. hospitals received a 5-star rating on patient satisfaction, Tampa-based facial plastic surgeon Dr. Rich Castellano is incorporating non-verbal communication training to further his practice’s patient satisfaction ratings. He marks the forefront of this relatively new training.

Making himself known as “The Smile Doctor,” Castellano has dedicated his practice to researching the effects of a doctor’s non-verbal communication on a patient’s quality of care. The author of The Smile Prescription, Dr. Castellano also travels the country to train doctors, healthcare providers, and entrepreneurs, and has been asked to teach students the power of non-verbal communication at his alma mater, the University of South Florida College of Medicine. “Patients are more proactive and trusting when they feel connected on an emotional level to a doctor,” Dr. Castellano reminds us, insisting, “this can greatly impact a treatment plan and improve the quality of care.”

Most notably in his material is his innovative Universal Smile Score scale, mimicking the ubiquitous 1-10 pain scale, to outline the facets and effects of differing intensities of smiles. Also ranked from 1-10, facial expressions ranging from blank stoicism to gut-busting laughter are broken down into eye involvement, visible teeth, and whether or not the face is socially encouraging laughter or smiling from a patient’s response. "At the end of the day, this is really about kindness and compassion,” he says, marking a bold and optimistic call to action for health providers.

It all boils down to a force of good, pushing proper bedside manner back to the forefront of patient care and doctor-patient communication. Dr. Castellano reminds us that healing is ultimately about experience and process, not just transaction, and that health care is about people and their emotional wellbeing, first and last.

What “The Undoing Project” Says About Healthcare Today

There are those who endure the wrinkle in time otherwise known as winter by counting the days until Pitchers and Catchers – that day of rebirth in mid-February when baseball’s pitchers and catchers report to spring training. But even if you’re not a die-hard fan, you would be thinking at least a little bit about the intricacies of the game if you’ve spent any time reading Michael Lewis’ new book, The Undoing Project: A Friendship That Changed Our Minds.

Lewis is the best-selling author of Moneyball, about how the underdog Oakland A’s general manager Billy Beane (played by Brad Pitt in the movie) revolutionized the business of baseball by using data and statistics to challenge how baseball players are valued. In The Undoing Project Lewis tells how, much to his own surprise, he learned that two Israeli psychologists had already done the ground-breaking, Nobel Prize-winning research that explained why Moneyball worked.

Lewis’ new book explores the intense, decades’-long collaboration between Daniel Kahneman (author of Thinking, Fast and Slow) and Amos Tversky. Together Kahneman and Tversky challenged some of the most deeply held notions about how our minds function by demonstrating how incomplete our judgments and illogical our decisions can be, especially when confronted with complexity, uncertainty and risk.

Their research exploring theories of cognitive bias has had some of its most significant influence in the medical realm. For example, Lewis tells the story of Dr. Donald Redelmeier, a Toronto internist and researcher whose job is, in part, to help trauma surgeons avoid mental errors in life and death situations.

One day a car accident victim is brought into Toronto’s Sunnybrook Hospital ER with multiple fractures in her ankles, feet, hips and face. When the young woman’s heart rhythm becomes wildly irregular the team can’t determine why and calls Redelmeier. But the woman is able to tell them she’d had an overactive thyroid; the team thinks that’s the cause, let’s treat it. When Redelmeier arrives in the trauma center, however, he urges the team to slow down and check their thinking. Hyperthyroidism is indeed a cause of irregular heart rhythm, but an infrequent one. He urges them to search for other, more statistically probable causes. And that’s when they find her collapsed lung and the fractured ribs that punctured it. They treat the collapsed lung and the woman’s heartbeat returns to normal.

“It was a classic case of the representativeness heuristic,” said Redelmeier. As proposed by Kahneman and Tversky, this heuristic holds that people often make judgmental shortcuts based on one situation being like another. Usually this works to our advantage but every so often sends you off in the wrong direction. Just because something is more representative does not actually make it more likely – although Kahneman and Tverksy’s experiments demonstrated that the mind doesn’t naturally see things that way.

Dr. Redelmeier acknowledged that for a hospital to employ him as, in effect, “a connoisseur of medical error” reflects how far medicine has come since he first started out, when doctors were considered (or considered themselves) infallible experts from whom complete certainty (or the appearance of it) was always expected.

This is part of the “undoing” that is happening in healthcare right now. Greater complexity is forcing both doctors and patients to work out new approaches to interpreting vast amounts of data, weighing benefit and risk, sharing information and communicating with each other so that better-informed decisions can be made. It is requiring everyone involved to challenge much received wisdom, just as Kahneman and Tversky – and the Oakland A’s – so profoundly did.

Biotechnology shows hope for the heart

This past summer there was a report of a scientific feat that should give biotechnology another reason to plant a flag with conviction. Kevin Kit parker of Harvard University’s Wyss Institute, together with a dedicated team, have announced their functioning bionic stingray. Made of engineered rat heart cells, it has the ability to swim with anatomically correct muscular contractions, and follow light.

Measuring 16 millimeters long, the tiny stingray boasts muscle made of 20,000 layered rat heart cells, built around a gold skeleton and flexible polymer. The cells have been genetically engineered to expand and contract like a muscular pump upon light exposure, ebbing through space exactly like a living stingray.

The team exemplified its ability by successfully guiding it through an obstacle course with an acute light source.

Fortunately, Parker is not interested in creating bionic animals, and wants to take the breakthrough to more directly beneficial spheres of science. “My real interest is in building a heart,” he says, explaining in an article by New Scientist magazine that the ultimate goal is to better understand the heart’s muscular behavior, and to decode heart disease.

Hanno Meyer of Bielefeld University in Germany insists the technology could, in essence, be taken much further. “The combination of artificial and living parts provides insight into creating a durable bio-hybrid system,” he says, “which could be relevant when creating new brain-machine interfaces.”

Parker’s work could confirm such a notion, as he’s also been involved in building mini-organs that could be manufactured and interconnected to create “a human on a chip.”

The Harvard team has previously succeeded in a more simplistic cell-built cyborg jellyfish as well, and now, according to New Scientist, is working on a “more complicated marine animal.” He won’t tell anyone what it is.

The breakthrough is a confirmation that biotechnology is a sector becoming more and more relevant, directly beneficial, and actionable. Beyond promising strides in agriculture and alternative energy, the medical fields may grossly benefit from its relevant advances, often lost under fears of GMOs and what many denounce as “playing god.”

We can be sure Parker and others will continue their work, and hope public opinion warms up to these incredible feats of ingenuity.

Wearing Our Hearts on Our Wrists

For now it tends to be the more motivated among us who sport Fitbits and the like in order to keep track of our steps, heart rate, diet, sleep, and other signs that we are alive and well. But the renowned cardiologist and geneticist Dr. Eric Topol sees a future when many more of us will be “digitized” with biosensors capable of measuring almost any physiologic metric – blood pressure, glucose, oxygen level in the blood, or impending signs of an asthma attack. “We will be able to send that data wirelessly through smartphones to our doctors, and use it ourselves maintain our health and direct our own care,” Topol told the Wall Street Journal in 2013, “and that is the essence of digitizing a human being.”

Facebook’s Mark Zuckerberg is all in, having recently told Topol that he wants to invest in and potentially be one of the first to try a novel technology Topol is working on now – a nanosensor put into the bloodstream that can sense a heart attack days or weeks before it actually happens.

In his book The Creative Destruction of Medicine, Topol is cheerleader for the power of digital, wireless technology to transform how health data is gathered, interpreted and put to use on both a macro, population health level and in the intimacy of the doctor’s office. He sees this as part of a great “inversion of medicine” that is already beginning to challenge established medical norms that date back centuries, where individuals will have much more access to their own medical data because they will be generating and owning it.

But to what degree could all this technological wizardry challenge the intimacy of the doctor-patient encounter rather than foster it?

We already have seen that with the advent of the electronic medical record there can be problems with too much “screen time” in the doctor’s office, as healthcare providers divert eye contact from the person in front of them to a computer screen. Topol sees the danger. As he has told the Wall Street Journal, “when you have this type of rich data on an individual, there’s a tendency to treat the scan or treat the DNA or treat the sensor data output rather than the patient.” But he argues instead that by “embracing the shift of much responsibility for data collection to patients, and its interpretation by artificial intelligence, the human factor of the doctor – establishing trust and support with extraordinary communicative skills and real intelligence – will be indispensible.”

New York Times columnist Thomas Friedman has coined the term “STEMpathy” to describe the jobs of the future that blend STEM skills (science, technology, engineering, math) with human empathy. “Nobody cares what you know, because the Google machine knows everything,” he recently told the Colorado STEM Summit. Rather, he argued, the future is about what we can do with what we know.

And that is true whether you are a person with a Fitbit, or an oncologist with access to IBM’s supercomputer Watson, which is being “taught” by doctors at Memorial Sloan Kettering Cancer Center to interpret cancer patients’ clinical information and identify individualized, evidence-based treatment options based on MSKCC’s decades of experience and research.

Seeing these trends as a democratization of information rather than technological consolidation and de-personalization is a challenging but also liberating way to envision the future of healthcare.

A Slice of Rao's Genius Branding

I love Rao’s® restaurant. Was there very recently and enjoyed it beyond all expectation. Make no mistake, the experience was seismic, intimate as it could have been outside a bedroom – wait staff literally sits at your table, pays real attention, even looks you in the eye (it’s NYC!), laughs at your jokes, all the while guiding you through your menu. Remarkably Rao’s has enjoyed this ride for nearly 120 years.

Standing center stage is Frank Pellegrino, the larger than life, master of his universe. He’s one of the owners and also of “Goodfellas” movie fame. A man who is preternaturally comfortable – with anyone. He finds your button and enjoys delighting you. Lucky us: He stayed at our table for hours. Such amazing, infectious, general exuberance and facility for storytelling and extensive knowledge of doo-wop, “music for the soul.” At one point, he was so into the moment, he grabbed my hand and sang a Frank Sinatra tune in front of my wife and dearest friends. Mind-blowing.

The space is small, 10 tables, but overflowing with pictures of everybody big – in sports, entertainment, you name it. What gave me instant street cred that night? He found out I spent my birthday a few years back at Sinatra’s Palm Springs house. Add that to the fact I was dining with a close friend of his family. What a night. It got later and later and no one noticed. From table top to bar stool, I ascended in to gastronomic heaven!

He walked us to our car late that night and allowed, not unsurprisingly, that he’s “as happy as a person can be. When I wake up, I ask: ‘God, what can I do for you today?’ God has blessed me with so much, I welcome opportunities to give back.”

So in a very real way, East Harlem owns Italian food. Let’s note too that Rao’s, as a brand, has embraced jars of “gravy” sold throughout America – “my home run,” as Frank refers to that side of his dynasty.

I mention all this about Rao’s because it sits at the rare firmament of great personal experiences. The experience is not replicable. In the most the positive way, it executes your senses. It delivers beyond what’s preconceived in your head. You can’t be there and not be intoxicated – figuratively and literally — by the care taken with the food, the music; by watching people indulge themselves; by the space and the ultimate beauty and magic of a New Yorker’s old New York. One doesn’t forget these things.

Its air is so rarefied it remains successful in the face unremitting change – no matter how super-instantly- connected we become, Rao’s makes its bones every day in the oldest-school way: By killing pretense and keeping its promises. (On some occasions, it’s alleged, when A-list celebs are in the house, Frank will confiscate all mobile devices and hold them at the bar.) Rao’s essence is imbedded in the sacred tradition (experience) of sitting around a fire singing, tell stories to each other, and eating like fools – the very experiences that makes us all happy campers.

Frank sums up his approach to trailblazing: Keep your nose firmly planted in what you know, while coming up for air long enough to fret about what you don’t. Anticipate what’s around the corner. Seeing the Road Ahead is why Rao’s opened in Las Vegas/LA and continues pleasing everybody lucky enough to snag a table. Not even Warren Buffet can “charm” his way into a seat! Read about epic battles over tables.

Healthcare in 2016: Boundless Opportunities to Make a Difference

It is one of the most invigorating times to be thinking about, caring about, talking about and working in healthcare. There continues to be great progress for the better, despite the many hurdles, twists and turns along the way.

This isn’t always obvious. So much of the healthcare conversation is approached narrowly through political or economic lenses. And it can get complicated. That’s why it’s important to keep some things that are actually quite basic in mind, especially about the role of communications in improving just about every facet of how the healthcare system operates and the outcomes that result.

One of the most fundamental shifts taking place right now is the shift from fee-for-service to value-based care. The Patient Protection and Affordable Care Act (ACA) generated an array of new organizations and payment models aimed at improving both cost savings and quality of care. This falls within a larger movement toward improving care quality and outcomes by making it more patient-centered.

As a result of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), by 2020 physician practices meeting not only process improvements but also quality and outcome improvements will be reimbursed by Medicare at a substantially higher rate than those who don’t (and those who don’t will be subject to reimbursement penalties). This marks a dramatic shift in how doctors are to be paid and, according to a report from the Physicians Foundation, many are finding the prospect daunting enough to think about throwing in the towel once and for all by retiring.

Many factors contribute to delivering patient care that improves outcomes, and the entire system will be challenged in ways large and small as new payment models are implemented. But one essential of quality care is – and always has been – the efficacy of the dialogue that takes place between clinicians and patients so that well-informed treatment decisions can be made, and so that patients are more engaged in what they themselves need to do to maintain good health or to manage acute or chronic illness. A recent article in Health Affairs said it best: “Patients are the most underutilized resource to help reach positive medical outcomes.”

One unique payment model – the Pioneer Accountable Care Organization (ACO) Model, which was developed as a pilot program through the ACA – brought $384 million in savings to Medicare in 2012 and 2013 combined, while providing high-quality care. And there was this interesting result: patients in the Pioneer ACOs reported higher ratings in timely access to care and clinician communication compared to those reported by FFS Medicare beneficiaries as a whole and their Medicare Advantage counterparts.

Before anything else, however, people need access to care. And right now, for better and worse, access is structured about the ACA. Word has it that the ACA is in a “death spiral.” This has been a perennial diagnosis since it’s inception.

The latest inflammation in the “death spiral” narrative was triggered by the highly-publicized retreat of Aetna and United Healthcare from participation in many state-run health exchanges (ostensibly due to significant losses on the exchanges but also, at least in the case of Aetna, following a Justice Department ruling against its planned merger with Humana). A closer look at the challenges reveals, among other things, a need for greater engagement with hard-to-reach segments of communities (including healthy young millennials) about the value of coverage, preventive care and the actual options that exist on the exchanges at local levels, so that pools of beneficiaries are better balanced between those who are healthy and those who are less so.

The movement toward a more sustainable system that better meets the needs of individual patients and whole communities seems, to me, to be inexorable, and the opportunity for communicators to make a difference seems boundless. There’s a lot to do and it is an inspiring time to be part of the conversation.

Through the (Google) Glass with Autism

The “gee-whiz” factor got knocked out of Google Glass pretty quickly. A little over two years after it was introduced to the public in a test version, Google put Glass back under deep research cover after people developed an almost instinctive aversion to its “in your face” intrusiveness, not to mention its poor functionality.

One of the biggest criticisms was how much people felt the device got in the way of social interaction. But in a different take on this technology and its potential, Google Glass is now being used as a means to help children with autism better recognize human emotions and navigate their social worlds. At least two groups of researchers are developing apps for Google Glass to help children with autism better “read” the facial expressions and social cues of those around them. In doing so they are exploring some fascinating intersections between neuroscience and the nature of human interaction.

At Stanford, the Autism Glass Project completed a Phase I clinical trial last year in which children wore the glasses and were “coached” by the device to identify the emotions on images on a monitor. When the device’s camera detects an emotion such as happiness or sadness, the wearer sees the word “happy” or “sad” or a related emoticon flash on the glass display. After completing a series of exercises, the children were better able to identify and differentiate the emotions they saw. They also looked more frequently at people’s faces and made more eye contact.

Now the researchers are recruiting families in the Bay Area (and soon nationally) with children (ages 4-17) with autism to participate in a study of Autism Glass as a therapeutic tool in the real world of the home environment. Kids will wear the device for three 20-minute sessions each day and Glass’s head motion tracking sensors and a custom-made infrared camera for eye tracking will be used to analyze the wearer’s behavior while interacting with family members and friends. Whatever the wearer sees can be saved onto a smartphone app for parents and children to review together later, facilitating discussion about emotions and their real-life contexts. The idea is not so much that people will wear the device all the time, but that it will aid in the treatment process during behavioral therapy. In an abstract the researchers point out that “computer-assisted in-place treatment systems have been studied for years, little work has been done to bring the learning process away from the flashcards and into the daily life of people with autism spectrum disorder.”

In Cambridge, Mass., the start-up Brain Power , founded by neuroscientist Ned Sahin and based on brain science developed at MIT and Harvard, has developed a suite of applications for its “neuro-assistive wearable device” using the Google Glass platform. In one of the apps focused on social interaction, the wearer sees two small icons on their screen when looking at a face, and by nodding slightly can choose one or the other that best represents the emotion being expressed. The wearer earns points for each correct selection. A key aspect of this approach is that feedback and reward all happen in real time, during real interactions, and encourages further interaction rather than the self-immersion more typical with computer-based learning. Brain Power is sponsoring the “BE YOURSELF” clinical trial to further investigate this and other applications for children and adults on the autism spectrum.

It’s comforting to know that a powerful technology like Google Glass just isn’t that exciting anymore if all it does is enable us to surf the web or check our emails faster. And it’s inspiring that the potential of this technology is being tapped in a completely different way to help understand and solve the most human of challenges.

Navigating The Polarities of Social Media

If there’s one thing this term’s political conventions are showing us, it’s the polarity of contemporary America. While each wing seems to be slowly and worryingly radicalizing, an interesting New York Magazine cover story this week suggests that it doesn’t stop at the opinions of constituencies. In a hugely telling, borderline damning, and certainly self-deprecating article, New York Mag dives inwards to explore the flaws of contemporary mass media by interviewing the influencers. One issue stands out: that the industry has stopped challenging bias, and has begun accommodating it—“a kind of blindness” that stems from a desperation to be respected. Only further antagonizing this new media climate, another respondent prophetically claims social media has created an audience able to “find the people that say what [they] want to hear”.

From a bird’s-eye, conceptual vantage point, suddenly nothing seems more true. One voter who can’t stand the rhetoric of Fox News is counteracted by someone who cuts all Trump criticisms from their Facebook news feed. If you’re a metalhead, you can tailor a new Twitter account in five minutes to block out any mention of Kanye West. Consider the magnitude of that power; that anyone can now take a story plastered through the check-out line tabloids and half of this morning’s radio conversation, and simply say “no thanks”—a requested that is instantly and fully accommodated without question. In terms of media, we now each create our own worlds, our own realities.

It’s not an overly surprising state of affairs, as modern consumers know what they want, and what they want to hear. Access to information has made being culturally and politically literate a complete 101-level task, and anyone can now occupy a niche, take a side, have an opinion, and denounce opposing spheres. Media is now accommodating by becoming specialized, so as to stay respected, and reaching ears that shave against your grain is therefore becoming harder and harder. Saying “the right thing” is going to be more and more dependent on understanding your current loyalists, and brand personality will need to be strong and relatively niche to rack any up at all. Pleasing everyone may soon be an impossibility. Likely will this further confirm the rise of “big data,” providing answers to the questions we need to understand the buyers behind a brand, and their behavior.

We already talk about Millennials as a unique, outlier breed, and how brands often need to bend over backwards to keep them entertained. But a new conversation may be rising, that the question won’t be “how do we reach millennials.” It might be “how do we motivate politically conservative millennials,” or “how can we win street cred with the hardcore hip-hop enthusiasts.” Avant-garde consulting firm K-Hole remarkably insist that being “unique” has become so typical, that the only way to stand out is to be as bland suburbia as possible—coining the term “normcore” and spurring a style movement. When one generation breaks into thousands of cultural compartments with loyalty, which ones are you going to align with?