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Monday, 2 May 2016

Princess Health and Who Benefits? - Hospital Profits and Quality May Fall, But Hospital Executives' Compensation Keeps Rising. Princessiccia

Princess Health and Who Benefits? - Hospital Profits and Quality May Fall, But Hospital Executives' Compensation Keeps Rising. Princessiccia

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Despite recent attempts at health care reform, US health care dysfunction seems to proceed inexorably with ever rising costs, and continuing problems with access and quality.  A likely reason is that those who find the current system personally profitable are in a position to resist real reform.  The people who seem to gain the most from the status quo are top hired executives of big health care organizations.

In particular, stories about huge pay for hospital and hospital system managers continuously appear in the media.  For example, starting in October, 2015, we saw the following headlines:

- Pittsburgh, PA, October, 2015: "Former Highmark CEO Made Nearly $10 Million in 2014, Tax Records Show"
- Regarding Rochester General and Unity health systems in Rochester, NY, November, 2015: "Here's Why Execs Got Millions After Health Merger"
- Regarding the CEO of North Shore-LIJ Health System in NY, November, 2015: "This Guy Makes $10M a Year to Head a Nonprofit"
- In Idaho, February, 2016, "Pay for 9 Treasure Valley Nonprofit Hospital Employees Hits or Tops $1 Million"

Even more interesting are stories that show massive compensation of executives despite their hospitals' apparent poor performance.  Since October, 2015, we also found the following (in chronological order)


Let Go After "Uneven Financial Performance," CEO of Kaleida Health Got $1.6 Million of Severance in One Year, with More to Come

In November, 2015 the Buffalo (NY) New reported that James R Kaskie, the CEO of Kaleida Health, the "largest healthcare provider in Western New York," per its website, was "forced out" when

the board cited a need for a change in leadership amid an uneven financial performance for the system....

Nonetheless,

Kaleida Health paid $1.6 million in 2014 to its former CEO, James R. Kaskie, after forcing him out early last year, according to its most recent federal regulatory filing.

Also,

Kaleida will pay Kaskie 24 months of severance under the terms of Kaskie�s employment contract with the system, John R. Koelmel, chairman of the Kaleida board, told The Buffalo News on Thursday.

Kaskie was paid 10 months of severance plus deferred compensation, which is the $1.6 million reflected in the latest regulatory filing. He will be paid 12 months of severance in 2015 and a final two months of severance in 2016.

Mr Kaskie was paid even better the year before:

Kaskie earned $1.9 million in 2013, his last year as CEO.

Furthermore, other executives who were let go after Mr Kaskie's departure also were very well paid,

Dr. Margaret W. Paroski, former executive vice president and chief medical officer, who was replaced by Lomeo after he took over as CEO last year, $763,552.

Joseph M. Kessler, former executive vice president and chief financial officer, who was replaced by Lomeo, $608,454.
The article explained that

Hospitals, corporations and other entities negotiate severance agreements as part of the employment contracts when they hire top executives
So not only to these executives earn top dollar, but their earnings continue even if they lose their jobs because of poor performance. When asked to explain these levels of remuneration, and contracts that allow executives to get continuing pay even after being "forced out" for "uneven financial performance," John R Koelmel, the chairman of the system's board, said

Companies pay at market. To recruit the best talent, you need to pay at least market.

Public Hospital MetroHealth Medical Center Scored Below Average on Patient Satisfaction and Quality, but CEO Got $1.1 Million

In March, 2016, Cleveland Ohio television station NewsNet5 reported

MetroHealth Medical Center is a public hospital that is supported with $32.4 million of taxpayer money--roughly 5 percent of the hospital's budget.

Also,

a check with a federal database of patient satisfaction levels and quality measures at hospitals across the country found MetroHealth fell below the national average.

Nonetheless, its CEO, Dr Akram Boutos, got $1.1 million in salary, and presumably considerably more in bonuses.

Dr J B Silvers, '"a nationally recognized expert on hospital CEO compensation and professor at Case Western Reserve's business school," who is a MetroHealth board member,

insisted that Dr. Boutros is being fairly compensated when compared to his peers. 

Furthermore,

He admitted the salary is first tied to profits--then a series of other quality measures like patient care, diversity, hospital improvements and employee satisfaction.

But the ties to satisfaction and quality may not bind, because he then tried to explain away the quality and satisfaction data,

Silvers argues those surveys may be misleading.

'Populations like ours, Medicaid populations, uncompensated care--poor people tend to rate organizations lower,' said Silvers.

But then admitted it was really about the money,

'We have to have a target in terms of financial performance because if you don't make the money you can't be in business,' said Silvers.

In Massachusetts, "As Hospital Profits Fall, Executive Pay Soars"

In April, 2016, the Lowell (MA) Sun published a long report on local hospital executive compensation.  It started

It has been a lean couple of years for the region's hospitals.

Drawn by the higher reimbursement rates that insurers pay to academic teaching hospitals, such as those in Boston, more physicians are affiliating themselves with those institutions. Patients are following, and so is the money.

Some community hospitals, including Lowell General Hospital and Emerson Hospital in Concord, saw profit margins drop by more than half from 2012 to 2014.

Other hospitals' financial indicators, like ratios of assets to liabilities, are also weakening,...

However,

As they look to weather those storms and protect their space in a rapidly changing health-care landscape, the boards of directors of the region's hospitals have doubled down on a key investment: their executives.

'Each organization has to make its own decisions about how it can best compete in the marketplace,' said Gary Young, director of Northeastern University's Center for Health Policy and Healthcare Research.

Senior executives of hospitals and health-care systems -- there's a competitive market for that kind of talent ... some would say when organizations run into trouble, they need to spend more to get leaders.'

So,

At Lawrence General Hospital, compensation paid to top non-physician administrators increased 41 percent from 2012 to 2014, according to tax documents. President and CEO Dianne Anderson, who heads the list, was paid a total package of $884,092 in 2014.

Also,

From 2012 to 2014, Lahey Health's non-physician executives saw a compensation increase of 36 percent. A large part of that increase was in the salary of Dr. Howard Grant, who was promoted from president and CEO of Lahey Clinic to president and CEO of the entire Lahey Health system. The system includes facilities throughout northeastern Massachusetts and southern New Hampshire. Grant received $1.7 million in 2014.

In addition,

Lowell General Hospital's executives saw a slightly smaller increase during that three-year span, at 18 percent, although CEO Normand Deschene remains the highest-paid hospital executive in the region with a package worth $1.9 million in 2014. The hospital also pays the taxes on retirement benefits, which are worth hundreds of thousands of dollars, for Deschene and several other executives.

The justifications for these increases in times of financial trouble were similar.  For example, re Lawrence General Hospital,

'Because we're resource-limited, compared to (academic) hospitals, we're even more dependent in these challenging times to bring in somebody who can manage risk,' said Richard Santagati, chairman of Lawrence General's executive compensation committee. 'It takes a different breed and there's real competition for these people ... and once you have them there, you want to keep them because there's a learning curve there that is unique to each hospital.'

Re Lahey Clinic,

'Our executive compensation is comparable to the programs of other, similarly sized health networks and is reflective of the complex role of an executive leader at a leading health system,' Lahey Health said in a statement.

Finally, at Lowell General Hospital, the CEO defended his own pay:

'Lowell General has weathered significant changes in the delivery of health care,' Deschene said. 'At a time when many hospitals have failed, it's very crucial and critical that we have very talented individuals to lead the hospital.' 

The Usual Talking Points Again Invoked

Hospital management used the usual talking points to justify the pay they received,  As I wrote last year 

It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they are talking points, possibly crafted as a public relations ploy. We first listed the talking points here, and then provided additional examples of their use. here, here here, here, here, and here, here and here. 

They are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).
So in the stories above, we found, for example:

- Competitive Rates: "you need to pay at least market" (Kaleida), and "there's real competition for these people" (Lawrence General)
- Retention: "you want to keep them" (Lawrence General)
- Brilliance: "the best talent" (Kaleida),  "very talented individuals" (Lowell General)

It appears that those justifying huge executive payments have all been handed these same talking points.

Yet none of them quite make sense.  The brilliance argument is particularly suspect in cases like those above of CEOs whose hospitals' performance was clearly not brilliant according to the metrics supposedly used to judge them. 

Economists Challenge the Management Dogma Justifying Huge Executive Compensation

Furthermore, these talking points seem to derive from decreasingly credible current management dogma about executive compensation propagated by business schools.

The Invisible Hand, or A Hand on the Scales?

For example, writing in the Independent during January, 2016, Ben Chu questioned the market fundamentalist theory that all employees pay has been perfectly chosen by the infallible invisible hand of the market:

When confronted with an outburst of public anger over massive corporate pay for a privileged few, a common response of the libertarian right is to invoke the economics of the free market.

Such spectacular rewards, we�re informed, are delivered by individuals selling their labour in a free market. And because such pay levels were set through this natural process, no one has the moral right to question them. Further, to interfere with such natural processes would be economically inefficient, making us all worse off in the end.

Such contentions are based on

a venerable economic theory [that is] behind this kind of reasoning. At the end of the 19th century, the American economist John Bates Clark hypothesised that in a perfectly competitive economy, demand for labour is determined by its 'marginal productivity' and wage rates are determined by the 'marginal product' of labour.

To translate, if a firm can make a profit by adding another worker to its payroll, it will do so. And the amount a firm will be willing to pay for that labour in wages will be determined by the additional profit the individual worker adds to the company�s bottom line. So if a worker adds a lot of profit, he or she can command a lot of compensation. But if they add only a little profit, he or she will get only a little. This means people with low personal productivity get small amounts. But people with high personal productivity (chief executives for instance) receive big bucks.

For a start, how does a company know what the marginal product of an individual worker is, or will be? This isn�t something that is directly measurable. The vast majority of us work in teams; how is it possible for management to determine our individual contribution to the financial success of that team, or of that team to the company? How can a business know how much of the profit added was due to the individual�s particular skills? The conditions necessary for the Clark theory that everyone gets what they 'deserve' don�t exist.

But isn�t the marginal product of bosses, who make big strategic decisions, easier to measure? The ASI cites the late Steve Jobs of Apple as an employee who was clearly worth a lot. However, there are plenty of other chief executives whose individual contribution is impossible to measure. Yes, the company�s share price might have gone up. But was this because the boss was smart? Or just lucky?

Furthermore,

The economist Dani Rodrik, in his latest book Economics Rules, argues that such broad theories of income distribution by the market are best viewed as intellectual 'scaffolding', adding: 'They are shallow approaches that identify the proximate causes but need to be backed up with considerable detail'.

And there are other theories of wage determination that are likely to be relevant. One important one is bargaining theory. This suggests that those who have political power within a firm can extract more than those without it. Maybe the reason chief executives tend to get paid ever growing multiples of the pay of the average worker is not because they are 'worth it' but because they are powerful. As the economist JK Galbraith put it: 'The salary of the chief executive of a large corporation is not a market award for achievement. It is frequently in the nature of a warm personal gesture by the individual to himself.'

The Dangers of Pay for Performance

In a February, 2016, article in the Harvard Business Review, Cable and Vermeulen challenged the dogma that managers' (and in health care, physicians' and other professionals') pay should largely be based on "performance."

performance-based pay can actually have dangerous outcomes for companies that implement it.

They cited five points based on at least some research evidence to back up their contention.

1. Contingent pay only works for routine tasks. Companies should abolish contingent pay for their top executives because theirs is the least appropriate job for it. Decades of strong evidence make it clear that large performance-related incentives work for routine tasks, but are detrimental when the tasks is not standard and requires creativity.

***

2. Fixating on performance can weaken it. The goal of most executive incentive plans is to focus leaders on hitting goals and achieving outcomes. After all, that�s why it�s often called performance-based pay.' But as researchers have found, if you want great performance, performance is the wrong goal to fixate on.

Several studies have shown that when employees frame their goals around learning (i.e., developing a particular competence; acquiring a new set of skills; mastering a new situation) it improves their performance compared with employees who frame their work around performance outcomes (i.e., hitting results targets; proving competence; seeking favorable judgments from others).

***

3. Intrinsic motivation crowds out extrinsic motivation. When people feel intrinsically motivated, they do things because they inherently want to, for their own satisfaction and sense of achievement. When people are extrinsically motivated, they do things because they will receive bigger rewards. The goal of contingent pay is to increase extrinsic motivation � but intrinsic motivation is fundamental to creativity and innovation.

***

4. Contingent pay leads to cooking the books. When a large proportion of a person�s pay is based on variable financial incentives, those people are more likely to cheat. In academic terms, we would put it this way: extrinsic motivation causes people to distort the truth regarding goal attainment.

When people are largely motivated by the financial rewards for hitting results, it becomes attractive to game the metrics and make it seem as though a payout is due. For example, different studies have shown that paying CEOs based on stock options significantly increases the likelihood of earnings manipulations, shareholder lawsuits, and product safety problems. When people�s remuneration depends strongly on a financial measure, they are going to maximize their performance on that measure; no matter how.

***

 5. All measurement systems are flawed. Incentive plans demand that some metric be used as the trigger for a payout. The problem is that whatever package you construct � bonds, stocks, or bonuses � whatever performance criteria you decide on will be imperfect. For a complex job such as senior management, it is simply not possible to precisely measure someone�s �actual� performance, given that it consists of many different stakeholders� interests, tangible and tacit resources, and short- and long-term effects. Even with HR executives clamoring for enhanced �people analytics� (and technology companies bending over backwards to deliver them) any measure you choose is going to be an inadequate representation of how you would like your CEO to behave.
Note first that these points suggest that the increased use of performance based pay for health care organizations' top managers may explain why many health care organizations actually perform so badly, and point 4 may help explain why pay for performance may actually help increase health care corruption.  

Note further that pay for performance (P4P) for health care professionals has been strongly pushed by many health policy experts, yet all these points also seem applicable to that usage.

Conclusion - Change Will be Resisted

So even when non-profit hospitals and hospital systems perform poorly, their executives continue to receive ever greater remuneration.  The executives, their public relations flacks, and their often compliant boards of trustees continue to cite the same stale talking points to justify their pay.  Yet these talking points are based on market fundamentalist theory and business school dogma whose credibility is increasingly challenged.  In the absence of anyone willing to confront them with these criticisms, the apologists for soaring health care executive pay continue to prattle their tired talking points.    

Meanwhile, as corporate governance expert Robert A G Monks said in a 2014 interview,
Chief executive officers' pay is both the symptom and the disease.

Also,
CEO pay is the thermometer. If you have a situation in which, essentially, people pay themselves without reference to history or the value added or to any objective criteria, you have corroboration of... We haven't fundamentally made progress about management being accountable.


Moreover, top health care executives' power to make warm personal gestures to themselves correlates with the ability to defend this power, per Mr Monks,
People with power are very reluctant to give it up. While all of us recognize the problem, those with the power to change it like things the way they are.
So I expect that many hospital and health system CEOs, like leaders of other big health care organizations, may talk about health care reform, but will avoid talking about, and will likely oppose attempts at real reform using their command of their organizations' marketers, public relations flacks, lobbyists, and lawyers.


We need true health care reform that would enable leadership that understands the health care context, upholds health care professionals' values, and puts patients' and the public's health ahead of extraneous, particularly short-term financial concerns. We need health care governance that holds health care leaders accountable, and ensures their transparency, integrity and honesty.  What we will get is endless resistance to such reform from those who personally profit from the current dysfunctional, and increasingly corrupt system.

Sunday, 1 May 2016

Princess Health and May 1st, 2016 Again and Again. Princessiccia

Princess Health and May 1st, 2016 Again and Again. Princessiccia

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May 1st, 2016 Again and Again

What an amazing weekend! It started with stand-up and ended with my grandson Noah. It was busy, but fun. Except for some photos, I'm allowing this to be a Tweets Only post. I'm off work tomorrow in order to accompany mom to a medical procedure she's having in the morning. I'm picking her up very early for the short drive to the hospital. We're planning on lunch out somewhere tomorrow midday.

photo IMG_2877_zpsatqxkxzs.jpg
Friday Night's opening stand-up set at the Big 80's Rock & Roll show with Dead Metal Society. Photo Credits: Richard Gorremans https://www.facebook.com/NightLightImages/
If it hadn't been for the epiphanies of May 15th and 19th, 2014--I would've never started doing stand-up again after such a long absence. It's one of my core elements and I enjoy nurturing that part of me as often as my schedule allows.

photo IMG_2793_zpsnvje7vk9.jpg
This guy, oh my...He brings joy to any room, any time. We had a little family get together at my daughter and son-in-law's new house. I made my guacamole for everyone! Noah did the cutest thing. He tried some guac, made a disgusted face, then tried it again--then made another disgusted face--then he tried it again and again until, I don't know--I suppose he decided it wasn't bad. He had Amber and me laughing out loud.

Today's Live-Tweet Stream:
































Thank you for reading and your continued support,
Strength,
Sean

Princess Health and State and national smoke-free leaders tell Ky. advocates to focus on local smoking bans because of political climate in Frankfort. Princessiccia

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By Melissa Patrick
Kentucky Health News

More Kentucky localities are likely to see efforts for smoking bans, as a statewide ban appears less likely and leading advocates are saying to go local.

Stanton Glantz
photo: ucsf.edu
Stanton Glantz, one of the nation's leading advocates of smoke-free policies, said at the Kentucky Center for Smoke-Free Policy's spring conference April 28 that California initially had trouble passing a statewide indoor smoke-free law, which forced advocates to move their efforts to the local level. By the time the statewide law passed, 85 percent of the state was covered by local ordinances.

"I'm glad it worked out that way, because we are really talking about values and social norms and community norms and you just can't impose that from the outside," Glantz said during his keynote address. "And so all of these fights that you are having in all of these towns. ... In the end, when you win, you've won. And the fight itself is an important part of making these laws work."

Ellen Hahn, a University of Kentucky nursing professor and director of the smoke-free policy center, also encouraged her colleagues to shift their efforts to localities, saying the political situation doesn't support a statewide law. New Republican Gov. Matt Bevin doesn't support a statewide ban on smoking on workplaces, saying the issue should be decided locally.

"We are in a very difficult political climate in Frankfort," Hahn said in her opening remarks."We all know it. We all recognize it. And while we would all like to see Frankfort do the right thing � and it will someday, I promise � it is not the time to let somebody else do it. It is the time to go to your local elected officials and say we want this."

Advocates made some headway last year when a smoking-ban bill passed the House, but it was placed in an unfavorable Senate committee and never brought up for discussion. This year's House version of the bill, in an election year with Bevin in the governor's office, was dead on arrival.

Glantz, a University of California-San Francisco professor and tobacco-control researcher, looked at the bright side: "You're in a tough political environment, but you are really doing pretty well." He reminded the advocates that one-third of the state is covered by indoor smoke-free ordinances, with 25 of them comprehensive and 12 of them including electronic cigarettes. He also commended the Kentucky Chamber of Commerce for supporting statewide and local bans.

What's next

Glantz urged the advocates to "empower and mobilize" the 73 percent of Kentuckians who don't smoke and get them to help change the social norms. Two-thirds of Kentucky adults support a comprehensive statewide smoking ban, according to latest Kentucky Health Issues Poll, and have since 2013.

�The whole battle is a battle about social norms and social acceptability, and once you win these fights, and you have a law that�s sticking � which takes a while � you don�t go back,' he said. "And the tobacco companies understand that, and that is why they are fighting us so hard.�

Glantz armed the smoke-free warriors with research data to support smoke-free laws, including: they decrease the number of ambulance calls; hospital admissions for heart attacks, stroke, asthma and chronic obstructive pulmonary disease; and the number of low-birth-weight babies and complications during pregnancy.

"In Kentucky communities with comprehensive smoke-free laws, there was 22 percent fewer hospitalizations for people with COPD," Glantz said, citing one of Hahn's studies. "That is a gigantic effect, absolutely gigantic, at almost no cost and it happened right away."

He noted that politicians are usually most interested in this short-term data, but he also cited long-term statistics about how smoke-free policies in California have decreased heart disease deaths by 9 percent "in just a few years," and lung cancer by 14 percent in about 10 years. Kentucky leads the nation in both of these conditions.

"I would argue that the economic argument is actually on our side," Glantz said, noting that economic benefits of smoke-free laws are almost immediate, especially because "every business, every citizen and every unit of government" is worried about health care costs. He also cited research that found "as you pass stronger laws, you get bigger effects.'

Princess Health and Leading tobacco foe is fighting Big Tobacco again, this time because the industry has taken over the electronic cigarette trade. Princessiccia

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By Melissa Patrick
Kentucky Health News

One of the nation's top anti-tobacco advocates told his Kentucky allies last week that the debate about electronic cigarettes makes him feel like he's "gotten in a DeLorean and gone back to the '70s," like they did in the movie "Back to the Future."

Stanton Glantz
photo: ucsf.edu
"Is it bad? Is it polluting? Does it have second-hand smoke? Blah, blah, blah, freedom, blah, blah, blah," Stanton Glantz ranted at the Kentucky Center for Smoke-Free Policy's spring conference April 28, lamenting how Big Tobacco has taken over the e-cigarette business and is using old marketing strategies to get kids to use e-cigs.

"The business is being taken over by the big multi-national tobacco companies and they are the ones who are doing all the advertising," Glantz said. "They are the ones who are doing all the marketing to kids; they are the reason the use among kids is exploding."

Glantz, a University of California-San Francisco professor and tobacco-control researcher, acknowledged that e-cigs are less toxic than cigarettes. But he said that doesn't make them safe, and most e-cig users also use tobacco, so they are not reducing harm. He also blasted the claims that e-cigarettes help people quit smoking, saying the claims are anecdotal.

However, the Royal College of Physicians, a major British medical organization, just published a report that says those who use e-cigarettes to quit smoking have a 50 percent better chance of success than if using no aids or using nicotine patches without counseling, Sabrina Tavernise reports for The New York Times.

Glantz disagreed with the report. He cited a meta-analysis he published a few months ago that found e-cigs don't help people quit smoking.

"On average, smokers who use e-cigarettes are 30 percent less likely to quit smoking than smokers who don't use e-cigarettes,"he said. "So, they are extending the tobacco epidemic."

Glantz said that the British researchers predicted what they think is going to happen, but U.S. data shows what is happening. "They have collectively lost their minds," he said.

Youth and e-cigarettes

Glantz said that he would normally not encourage advocates to focus their efforts on children, because "kids do what adults do," but he said that isn't so with e-cigs, which are being directly marketed toward them with candy flavored products.

"I think e-cigarettes are different. E-cigarettes are different because this is an epidemic that is growing from the bottom up," he said. "And the data on kids is like very scary. Non-smoking kids who use e-cigarettes, if you come back a year later, they are three times more likely to be smoking cigarettes than the non-smoking kids who aren't using e-cigarettes."

Glantz wrapped up saying, "So, the bottom line on e-cigarettes is they are likely to prolong the tobacco epidemic because they are restoring social acceptability of tobacco use. They are depressing quitting among smokers and they are attracting kids to nicotine, a lot of whom are going to convert to cigarettes."

Glantz is best known for leading the movement to call out the deceptive marketing messages of cigarette manufacturers and expose the dangers of tobacco during the 1990s, with the help of documents showing that tobacco executives were aware of the dangers of their products while marketing them aggressively toward young adults and teens.

Glantz's current research focuses on the health risks associated with secondhand smoke and the correlation between high smoking rates and heart attack deaths. He also works to change policy that would mandate an "R" rating for any movie with smoking in it.

Saturday, 30 April 2016

Princess Health and JAMA LAYS AN EGG. Princessiccia

Princess Health and JAMA LAYS AN EGG. Princessiccia

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JAMA LAYS AN EGG 

Three months ago I took JAMA to task over a Viewpoint opinion piece about conflict of interest. The authors proposed dancing around the reality of financial conflict of interest in medicine by talking instead about confluence of interest. I countered with a proposal for the term competing interests, which would not paper over the problem. In that post I also included a letter I had sent to JAMA in response to the opinion piece, but which JAMA had declined to publish. I questioned whether JAMA had deep sixed all the critical replies it received.

Now I can report that, in the April 26, 2016 print edition, JAMA has finally published one critical letter and a replyfrom the original authors. So JAMA didn�t deep six everything. This new correspondence appears 174 days after print publication and 214 days after on-line publication of the original Viewpoint article. That glacial delay is problematic � it disables meaningful dialogue.

The new critical letter is from a group in Europe, and it thoughtfully discusses weaknesses in the Viewpoint authored by Cappola and FitzGerald. These Viewpoint authors did not do justice to the critical letter in their reply. Moreover, they disclosed multiple potential competing interests, but they did not follow their own advice by clarifying why we should disregard those obvious competing interests. As we all know, the mere disclosure of competing interests does not by itself remove the problem. It can be a device for hiding in plain sight. Substantively, the reply from Cappola and FitzGerald is mostly hand waving and restatement of biased opinion, without real analysis or incisive thought.

The closing sentences of their reply letter illustrate these issues: �Everyone has biases. Rather than present these pejoratively, as a clash of values that undermines validity, it seems more constructive to mine the complexity of these biases, present them in an accessible fashion, and seek to determine whether they are confluent with the interests of patients, scientists, and regulators who might base their decisions on the results of a given piece of work.� The reference to complexity of biases concerns the matter of nonfinancial bias like fame and careerism in science. The reference to presenting biases in an accessible fashion concerns the ill-considered proposal to include a bias heat map on patients� consent forms. This idea rightly was panned by the European critics. Meanwhile, where did the compromised and disgraced key opinion leaders disappear to in all this wishful thinking? Where did the corrupt corporations disappear to? They paid billions of dollars in penalties for felony crimes and plea-bargained settlements. They have been airbrushed out of the Cappola-FitzGerald narrative. These authors come across like Bambi confronting Godzilla.


If this is the best that an associate editor of JAMA and a fellow of the Royal Society can do then JAMA needs a fix. This effort is too little and much too late.

UPDATE 05-03-2016
Apparently the link to my earlier post is inoperative. My apologies. Here is a link that should work.
http://hcrenewal.blogspot.com/2016/01/jama-jumps-shark.html 
Princess Health and April 30th, 2016 A Bomb In Need Of Defusing. Princessiccia

Princess Health and April 30th, 2016 A Bomb In Need Of Defusing. Princessiccia

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April 30th, 2016 A Bomb In Need Of Defusing

I really enjoyed my day off today. I slept in, I spent some time helping my oldest daughter finish up her and her husband's move, I prepared some great food and enjoyed a fabulous date night dinner with Kristin for her birthday.

Navigating the menu choices at the restaurant this evening was fairly simple. I did ask a couple of questions and made one special request in order to ensure I got what I needed instead of something I didn't. Neither one of us touched the basket of cheddar biscuits on the table. I remember times, years ago, when a second and third request for more was made.

The accountability and support system coupled with the non-negotiable elements of my personal plan supports this different perspective. It's a perspective that doesn't require the food to shoulder the responsibility for whether or not an event is considered a good experience. I certainly enjoyed the food I ordered, but the experience, the conversation and the laughs is what made it great. A basket (or two) of biscuits wouldn't have enhanced the evening in the slightest. For me, it would have had an opposite effect had I sacrificed the integrity of my maintenance plan.

We visited a traveling carnival after dinner and arrived just as they were closing everything down. We asked the Ferris wheel operator if he could accommodate one last ride tonight, adding that it was Kristin's birthday. He referred us to one of the co-owners, who turned out to be the sister of the other owner, whom I had as a guest on my radio show a couple of weeks ago. I don't think that connection made a difference as much as Kristin's birthday request. The answer was, "sure, why not?"

Then, when the ride ended, one of the carnival workers honored Kristin's birthday by presenting her with the last funnel cake of the evening, compliments of Ottaway Amusements. We graciously accepted the gift, both of us knowing full well that it didn't fit in either of our food plans--and I carried it to the car for her. Kristin said I was handling it as if it were a bomb. I wasn't tempted in the slightest, seriously, but I totally get it--I probably was carrying it as if it were a bomb in need of defusing. Defusing it meant throwing it away, but we couldn't just throw it away right in front of the people who generously and thoughtfully presented the gift!

First, we tried to give it away to some people in the parking lot, but they declined our offer. Without a trash can close by and also out of sight of the carnival vendors, we hadn't a choice--we had to give this sweet thing a ride. The car quickly became thick with the aroma of funnel cake, so down went the windows.

We ended up transporting this powdered sugar topped creation less than a mile away before we found a place to get rid of it. But instead of simply throwing it away, we set it in plain sight just outside of a big Saturday night college crowd hangout and then, we waited for someone--anyone to notice this perfectly untouched, still warm funnel cake--just sitting there, unattended. Not one person noticed the funnel cake. After several minutes and a few laughs from the close calls, we left--knowing full well it would eventually make it into the trash can just a few feet away.

We stopped by mom's place to say hi and get a quick hug before heading out of town for the forty-two mile trip back. But before we hit the highway, we checked on the funnel cake--and still, there it sat in the company of literally a hundred or two late night partying college kids who were completely oblivious to it or the slightly humorous circumstance that rendered it unwanted and abandoned.

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Thank you for reading and your continued support,
Strength,
Sean

Friday, 29 April 2016

Princess Health and April 29th, 2016 An Equal and Opposite Reaction. Princessiccia

Princess Health and April 29th, 2016 An Equal and Opposite Reaction. Princessiccia

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April 29th, 2016 An Equal and Opposite Reaction

Whenever I allow my schedule to get loaded and crazy, it requires me to get extra aware of how I'm feeling and what I'm doing. I've shared many times about my parallel streams philosophy and how I mustn't allow the life stream and the fundamental elements stream to cross. It's a seemingly complex, yet simple philosophy drawn from my experiences over years and years of weight loss attempts, many of which served as a source of education, rather than a source of consistent and sustainable results. 

Maintaining the integrity of my fundamental elements stream (calorie budget-abstinence from refined sugar-the accountability and support connections, etc.) while the life stream is a little (or a bunch) bigger than usual, means adjusting the embrace of both, in equal measure. For every action there's an equal and opposite reaction. Making sure those reactions are in harmony with my personal plan, is key.

If I didn't hold on to the fundamental elements stream a little tighter during a bigger life stream schedule, then I'd quickly fall into chaos. I've been there many times. I'd prefer to not go there again, if I can help it.

For me, it starts with setting some non-negotiable elements. Even at extreme life-stream levels--we're talking super long days, heavily involved projects and all that might include--I have my minimum non-negotiable elements of the fundamental elements stream. I will maintain the integrity of my maintenance plan calorie budget. I will remain abstinent from refined sugar. And I will consume a minimum 64oz water. I will log everything in MyFitnessPal and I will compose and send the accountability Tweets. That's the bare minimum, for me, come what may.

And once I've accepted and embraced those non-negotiable elements--then it changes my perspective completely. Instead of finding reasons why it can't work under extreme schedules and circumstances, I'm exploring solutions for how it can work, and work well.

It's rarely perfect and it doesn't need to be perfect. This has never been about perfection, clearly. It's about remaining consistent in my continued recovery. In my experience, striving for perfection is the quickest detour to self-loathing based disappointment. Accepting a certain amount of imperfection doesn't mean I sacrifice the integrity of my non-negotiable elements. It means I might go a little longer between meals than is optimal. It means my choices, although still "on-plan," may not be the best or what I would have preferred. It means I might spend way too many calories on half & half in my coffee. Examples of these imperfections have littered the last few days.

A perfect example happened tonight, when the plan called for me to prepare a late meal at home. I picked up some fresh salmon earlier today for tonight's meal--the plan was baked salmon, oven baked sour cream topped red potato slices and asparagus. Instead, I called an audible when the show went long and the time became a little too late. I relented on the original plan and called ahead for a special order from Ground Round Grill and Bar. Baked cod prepared without the drenching of butter or bread crumbs--seasoned simply with salt & pepper, asparagus grilled well with a minimal amount of extra-virgin olive oil and 1/2 an order of fried sweet potato fries (which I still count as 1.5 servings as a way to compensate for the frying).

Maintaining these non-negotiable elements coupled with staying connected with one on one and group accountability and support contacts makes for another successful day. And today, despite a schedule rivaling yesterday's extremes, was definitely another successful day.

My original plan for today included working harder to leave the studio a little earlier. When severe weather fired up early afternoon, it immediately extended my broadcast day. Suddenly, the adjustments to the schedule became imperative. I made the adjustments and it turned out just fine.

I've had three stand-up performances in the last two days. One was disguised as a speaking engagement--but make no mistake, it was stand-up comedy. Tonight's show was a big one. I opened for one of the best cover bands in the United States. Dead Metal Society plays 80's rock and roll--and they do it with the most authentic everything--the clothes, the hair, the lights, the fog--the experience, with spot on musicianship and vocal impersonations--it's simply unbelievable.

I had a great set despite a couple of hecklers I was told about afterward. I was focused on my set and landing my punchlines well. I accomplished just that without really noticing the two idiots in the crowd of approximately five hundred. Could I have acknowledged and handled the hecklers? Absolutely. But not in a twelve minute opening set. It wasn't my show. It was DMS's show, and their audience. My mission was to provide a little warm up entertainment, get some laughs--set a tone for a good time and introduce the band. Mission accomplished!

I'm hitting the pillow late--with a wonderful plan of sleeping in, without an alarm. That will be an awesome thing!

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Thank you for reading and your continued support,
Strength,
Sean
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