Devil in the Details

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Processed meat was in the news once more this past week, and – brace for it- it’s bad for you again. Because, of course, it always was. 
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That doesn’t mean you can’t eat bacon or pepperoni; that’s up to you. You are the boss. But while everyone is entitled to their favored opinions and choices, not so facts. The facts are the facts, and the facts about processed meat are quite clear. We’ll come back to those and the new study momentarily.
First, I’ve noticed the inevitable during my travels of the past week: a whole lot of anxious conversations about the coronavirus. This is not entirely unfounded- the pandemic is alarming.  For those wanting good, up-to-date, expert intelligence about the virus, its spread, the risks, and suitable responses- they are available. We might all take a moment as well to reflect on how preventable such anguish and potential calamity might be if we would ever learn from the follies of history, be pro-active rather than always reactive, and if the court of public opinion reliably honored the brave and convicted the despotic, rather than the currently popular opposite.
My contribution is a reality check about risk. To date, the global death toll from the coronavirus- as I write this- is 638. The risk is not evenly distributed, of course, but if it were, it would at present mean a personal risk of death from this virus of roughly 1 in 12.5 million. If you bank at all on odds like that, do be sure to get your Powerball ticket today.
In contrast, measles, before there was a vaccine introduced in 1963, routinely killed over 2.5 million people a year, most of them children. The most recent statistics, fueled by global gaps in vaccine coverage and anti-vaccine conspiracy theories, are 140,000 deaths, again mostly young children, in 2018. Before the coronavirus is as bad as just a garden-variety-year for measles, it will need to kill 219 people for every one it has killed thus far.
The point here is that when it comes to the assessment of risk, we are, in a word, nincompoops. 
We routinely dismiss large risks genuinely likely to impact our lives, and exaggerate risks that are new, newsy, or exotic; we get wildly worked up for a little while about risks that come and go, while cultivating the contempt famously born of familiarity when risks stay and never stop stealing years from lives and life from years. Threats to you and those you love literally orders of magnitude greater than coronavirus don’t just hide in plain sight; you welcome them daily into your family kitchen.
With that in mind, let’s have a look at the new processed meat study, published in JAMA Internal Medicine. The study is of considerable size and careful methods. The associations between meat (especially processed meat) intake and adverse health effects are consistent with virtually all prior research on the topic, including the systematic reviews on which the contrarian, so-called “guidelines” last September were allegedly based. Those studies, too, found statistically significant harm- more death, more heart disease, more cancer, more diabetes- with higher intake of red and processed meat, they just graded certainty in their own findings as low, and chose to recommend...the opposite.
The magnitude of risk increase reported in the new study was relatively small, but as noted above, people worry routinely about risks vanishingly smaller- from plane crashes to sharks to lightning strikes.  At the level of just two servings per week, the authors found a roughly 7% increase in the risk of cardiovascular disease with processed meat, and a 3% increase with red meat. The risk of death was increased roughly 3% by both.
Are these really the “modest” risks they are reported to be? Consider that the current risk of death by coronavirus averaged over the global population and expressed as a percent is 0.000008%.
A 3-7% increase in the risk of heart disease or death that is entirely controllable by individual choice- is a very big deal. At the population level of the United States, 3% is 9 million people. For only the population over age 50, it's still well over a million. 
Roughly 3 million people die annually in the United States; a relative 3% bump in that figure is an additional 90,000 deaths. Does that sound like a small number- when you start thinking about 90,000 families anguished at the CCU, or grieving at the cemetery? Does that magnitude of unnecessary loss and grief sound...small?
That's the problem with universal exposures like diet and statisticians who forget that behind their “numbers” are actual people. Small shifts in risk at the individual level can add up to enormous differences in public health. There is nothing small about tens of thousands of entirely avoidable deaths or heart attacks every year.
The new study was observational, and those espousing a seemingly religious devotion to the exclusive merits of randomized trials are apt to wave it off accordingly. This, however, is entirely unfounded on the basis of science and sense alike. Most of what we humans know that matters most to making it through any given day- from the dangers of electricity and fire, to those of slippery shower floors or changing lanes in traffic- are entirely observational, and involve no formal studies at all- and certainly none randomized.
The risks of shark attack are vanishingly smaller than those of processed meat, and there are no randomized trials to corroborate them; should we, accordingly, issue guidelines encouraging swimmers to head toward, rather than away from, that ominous dorsal fin slicing the water? The risks of lightning are also vanishingly small compared to all of the above, and again- there are no randomized intervention trials to confirm what we think we know. So, are guidelines justified encouraging people to run around in thunder storms waving long metal poles? For that matter, most people who drink don’t get cirrhosis, and there are no randomized trials affirming the link for those who do. Guidelines, accordingly, to drink up, and livers be damned?
The rebuttal is equally robust from the realm of science. Hormone replacement at menopause was thought good for health based on observational studies, then bad based on randomized trials that seemingly missed baby for bathwater. Both were a bit right and both a bit wrong, and the current understanding, informed by both, is that women can experience net benefit or harm depending on personal circumstances and the specific version of hormones. There is no “one kind” of evidence that owns a monopoly on understanding.
There are some more interesting tidbits from the new study. The authors report that the adverse effects of unprocessed red meat were greater with higher overall diet quality. This is a very important point, easily overlooked. 
What it means is that if diet quality is poor overall - few fruits and vegetable, lots of highly processed food, lots of processed meat, lots of added sugar- the adverse effects of red meat are obscured, diminished, or disappear. That is because questions about any given food or food type always come down to: "instead of what?" If everything you eat instead of red meat is bad for you, and red meat is comparably bad for you- it becomes impossible to isolate the adverse effects of red meat. 
By way of analogy, running in intense heat without adequate hydration is “bad” for you- but if you are doing that because you and your platoon are ringed by enemy gun fire, a high casualty rate from gun fire will make the ills of dehydration inconsequential. But that doesn't mean they aren't real, or important- it just means they don't matter much, independently, when your overall situation is dire. And let’s be clear, the dietary situation in America is, indeed, dire.
Conversely, even unprocessed red meat was decisively harmful when diet quality was higher. That's because in such a situation, there is still room left for dietary harm to be done- it's not already maxed out. So, yes- relative to eating the more healthful alternatives- even unprocessed red meat is decisively linked to mortality and heart disease. There is just more than one way to eat badly, and substituting one of these for another is a lateral move.
Finally, the authors did a very careful analysis, which is, of course, good. But the reality is, foods are not isolated exposures; they contribute to overall dietary pattern. It is overall dietary pattern, and diet quality, that matter most to health.
People consuming higher levels of processed meat and red meat are, all but inevitably, consuming lesser amounts of the main alternative plant foods- legumes, whole grains, nuts, vegetables, etc.  The authors of the new study controlled for these, however. That's arguably a good thing in the service of methodologic purity, if the goal is to isolate the harmful effects directly attributable to meat and processed meat only. But it is also very unrealistic, because that's not how diet works in the real world; more beans means less beef in the real world, more beef means less beans. 
What all this means is that the real-world adverse effects of higher intake of processed and red meat are almost certainly, and perhaps very substantially, underestimated by this study. A realistic assessment of the actual risk in practice was sacrificed for a risk estimate that was unassailably defensible because of meticulous controls. No doubt noise will be made about uncertainties in these data- but while true, they almost all point in the direction of actual, real-world risks considerably higher than those reported.
Put this study in the context of all prior research on the topic, and it is a robust affirmation of what we already knew. We can, and should, inform our understanding of what is true, in nutrition and in general, from a variety of evidence sources that make different, but comparably important, contributions to the overall weight of evidence.
It’s been a very long time, but I remember liking the bacon and deli sandwiches I ate as a kid, the charcuterie I tasted when I first visited France. I wish they weren’t bad for me, worse for the planet, and all too often a product of callous cruelty and brutal abuse of our fellow creatures. But they just are. I subordinate the inclinations of taste to those of conscience. It’s easier than you think, because taste buds readily learn to love the foods they’re with. What you choose to do with both native taste and informed conscience is, of course, up to you, but the facts are not. And since there are ever new ways to avoid meat and taste it, too- perhaps there is a new détente possible between the predilections of palate and the relief of conscience.
As you chew on that, be sure to put the risks that compete for your attention into reasonable perspective. Coronavirus is scary, but thus far, very, very unlikely to affect you or anyone you love. Stay tuned, but keep calm and carry on. 
Conversely, just try to picture 90,000 variants on the theme of anguish written across the face of wife, husband, daughter, son, sister, brother. You won’t make it through the tiniest fraction of that sum before conceding- there is nothing small about it.
 
Dr. David L. Katz is a preventive medicine specialist and co-author, together with Mark Bittman, of the forthcoming How to Eat.
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As the CEO of a not for profit with an international network of chapters that hold regularly scheduled informational and networking events, I am always interested in increasing membership and engagement. Of course, social media is a critical part of our strategic marketing, communications and engagement plan.
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One way we do that is to live stream some of our chapter events that originate from locations from San Francisco to Denver to Barcelona.
By now, you have likely heard how effective video marketing is, but did you know Facebook Live videos receive 3X higher engagement than a video that is no longer live? Facebook Live videos also receive 5X more than standard photo posts, according to AdWeek.
Whether you’re trying to raise brand awareness, get more leads in the door, or increase interactions with your current customers, Facebook Live is a tool you should be using. Here are five ways you should be using Facebook Live in your marketing campaigns: 

Be sure you have someone knowledgeable about the technical aspects of using the platform to help produce and create the video.
Check to be sure that the WiFi in the location will support high quality live streaming.
Have a microphone available not just the presenter, but for audience participants who want to ask questions or engage as well.
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Ask the presenter to review the video before posting since they might have said something or demonstrate body language they would prefer not to publish.
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Use carefully selected key words and metatags to optimize SEO.
Repurpose the video or share generously on other video platforms like YouTube.
Make your message repetitive, redundant and relational, linking the videos to other marketing collateral like websites, newsletters, online posts and blogs. Here are the 7Rs of content marketing.
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Do not publish low quality videos. Learn from your mistakes and fix them when it comes time to produce the next one.

Scaling your business will depend on how you get, keep and grow customers. One way to do that is to show them, not tell them.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on [email protected] and Facebook.

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By now you know that things in the medical commerce world are rapidly changing.
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Patients are now referred to as customers and health professionals, much to their dismay, are now providers. Next they will be called sickcare retailers.
Online medicine is growing much like online commerce.
The retail apocalypse continues and hospitals are consolidating or closing.
Sick care sales and marketing is evolving to engage and educate patient customers and sickcare retailers are learning how to sell to them.
The buying experience and convenience has taken precedence over quality as a differentiator for medical facilities and clinicians. For patient customers, convenience care trumps value based care. That's why there is a doctor-patient values gap.
Price transparency is growing.
Online communities of patients with similar medical problems are ever present.
The digital ecosystem economy is evolving towards creating a whole product solution. Maybe some day you will be able to get your health records from an ATM.
Financial technologies are making it easier and more convenient to pay for sickcare products and services.
Healthcare professionals are being trained and held accountable for patient customer service.
The Consumer Electronics Show and the JP Morgan conference now gets more press coverage than most medical meetings.
Amedzon, Walmart and media companies are the new new sickcare things.

Consequently, don't be surprised when you see a medical department store move into that empty mall down the road from your house. The department store transformed America. Now some of the very forces that fueled its rise have been turned against it. The only way out may be for it to recapture something of its past.-making it an experience for a community.
Medical department stores will offer many different departments:

Wearables and other consumer medical electronics.
Clothing with sensors.
Telemedicine appliances and medical devices and other durable medical equipment.
Patient and care circle education centers.
A service department.
A medical geek squad.
DIY medicine departments with kiosks.
Patient and care navigators to help you connect to social service agencies to address the social determinants of heath outcomes.
Data navigators to help you make sense of all that data you are generating every day
Health, data and insurance IQ literacy resource centers.
Smart home furnishings, appliances and bathroom accessories, including our nextgen smart toilet.
Healthy food delivery services, kitchen appliances and cooking classes.
Discount travel agencies to arrange medical travel.
Primary care centers with an adjacent digital device, digital therapeutics and pharmacy, where you get that app your doctor prescribed downloaded and explained.
Retail dental clinics.

 
CBD dispensing robots are coming to select stores in Colorado.
You can even check into our adjoining surgitel to recover from your procedure at our day surgery center.
If you are worried by now about how you are going to compete with Applecare and Walmed, here are some tips on how to practice retail medicine.
Another benefit of all this one stop shopping is the food court (think Harrods) with a healthy food pharmacy and several bars where you can join your friends to avoid social isolation and loneliness. Fill out the form on our app to receive sales promotions and coupons and check out our low, low prices if you missed Black Friday.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on [email protected] and Co-editor of Digital Health Entrepreneurship.
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  ["title"]=>
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Staffing your healthcare startup team can be a challenge.
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You need people who can work in an environment of creative chaos while at the same time building the foundation of inevitable control as the company grows and scales.
In addition, there are differences between good rebels and bad rebels and disruptive and disruptive doctors.
In a recent book, Francesca Gino argues the value of staffing an organisation with leaders and employees possessing what she calls “rebel talent.” She backs it up with extensive research, much of it her own.
Gino, the Tandon Family Professor of Business Administration at Harvard Business School, builds her book around the “five core elements of rebel talent.” They are:

Novelty (“Seeking out the new”)
Curiosity (“Asking why, why, why")
Perspective (The ability to “constantly broaden (one’s) view of the world and see it as others do”)
Diversity (“The tendency to challenge predetermined social roles”)
Authenticity (Remaining open and vulnerable in order to connect with others and learn from them")

Here are some tips on hiring, developing and promoting rebels on your team:

Clarify the expectations.
Give a clear job preview. Do you really want someone who will shake things up or do you really just want an operator and team player in rebel clothing. Are you being hired to help with strategy, execution or both? What will be your role in the process?
Don't say one thing and do another.
Be sure your culture can tolerate rebels in their midst, Will you really be comfortable telling truth to authority?
Mentor and coach bad rebels into becoming good rebels.


6. Create clear key performance metrics.
7. Practice radical candour in an environment of trust.
8. Here is a boomer's guide to teaching millennials.
9. Be sure your actions reflect the values you promised when you hired the rebel.
10. Fire fast if they become the problem instead of the solution.
Try not to make these rookie entrepreneur mindset mistakes.
Good rebels can be difficult to work with but you should be accommodating to their personalities and mindsets. Rebels without a cause and bad rebels,, thought, are just a pain.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on [email protected] and Facebook.
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Kids benefit from less homework. Ironically, their parents are doing it more and more. Doctors are spending more and more pyjama time on electronic records and it is burning them out.
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Here are are the pros and cons of telecommuting. More than two-thirds of people around the world work away from the office at least once every week, according to researchers.
A study released Tuesday by Zug, Switzerland-based serviced office provider IWG found that 70 percent of professionals work remotely — a phenomenon known as telecommuting — at least one day a week, while 53 percent work remotely for at least half of the week.
But, when it comes to creating a startup, is doing it virtually a good idea? Here's how to create a virtual biotech company. Want to save thousands in your startup budget? Get a library card
Certainly, there are benefits. But, there are also potential downsides and challenges like:

The challenges of working in global virtual teams.


Building and measuring high performance teams.


Not getting out of your house to identify and analyse market signals.


Restricting your internal and external networks.


Reducing the chances of innovation seeding serendipitous interactions with other people.


Hampering your ability to build and scale a culture.


Having to go to all those coffee shops for those nasty but inevitably necessary face to face meetings. Finding an electrical outlet or a phone charger there is another story.


Running Zoom meetings with screaming kids and barking dogs in the background.


Loss of productivity when Comcast interferes with your broadband service or your dog eats your cable.


Having to go through an IRS audit because you screwed up your home office deduction.


Getting too comfortable at home might cause you to ignore your cognitive biases.


It's expensive to create an innovation space in your basement or spare bedroom. Plus, I mean, who decides what fabric to use to cover the sofa or whether to get a stand up desk or not?

Creating a successful startup is hard enough and will probably fail 90% of the time regardless of where or how you do it. Any computer knows that the success rate has more to do with whether you create a category killer than where you create it.
Arlen Meyers, MD, MBA is the President and CEO of the Society of Physician Entrepreneurs on [email protected] and Co-editor or Digital Health Entrepreneurship. 

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