Health for life

You read the Disease Management Care Blog and use its literature-based links.  As a result, you know a lot about shared decision making (SDM).   Based on the randomized control clinical trial data that are regularly linked by the DMCB, youre ready to implement it in your network of primary care clinics.  You call your physicians together for a meeting, explain SDM is the best thing since the invention of the Woods lamp and ask them to er patients to the program.

Except for the part about the DMCB, thats what basically happened at the eight highly regarded medical institutions: Dartmouth-Hitchcock Medical Center, MaineHealth, Massachusetts General Hospital, Mercy Clinics in Iowa, the Oregon Rural Practice–Based Research Network, the Palo Alto Medical Foundation, the Stillwater Medical Group in Minnesota and the University of North Carolina at Chapel Hill.  The decision aids covered approximately 50 common conditions such as knee arthritis and prostate enlargement

And it didnt work out.

To investigate what happened, investigators at RAND interviewed 23 "key informants" from the 34 primary care sites that had implemented the Informed Medical Decision Foundations shared decision making program. The interviews were conducted between December 2010 and March 2011.  Their study is published in the February issue of Health Affairs.

Three barriers were identified:

Overworked physicians: given all the other health care needs of their patients, it was difficult to count on physicians to distribute the decision aids.  As a result, only 10%-30% of eligible patients participated.

Overconfident physicians: many doctors felt that they were already providing sufficient patient education or that their patients would not benefit from the decision aids.  Just telling the docs that this worked was not enough.

Underperforming EHRs: the state-of-the-art information technology could not flag potential patents, remember which individuals had been exposed to the decision aids or record the patients perences.

The answers?

Well, if the someone from the eight institutions had simply called the DMCB and asked, it would have told them about the many times it explained stuff to a roomful of physicians and had zero impact.  There also good peer-reviewed literature on why its so difficult to change physician behavior. 

The DMCB ultimately found the answer is to take physicians out of the work flow.

Thats what the RAND researchers found.  Based on their interviews, they recommend that if youre going to implement SDM in your clinics:

 Automate the process as much as possible and remove human decision-making from the process the triggered the decision aid.  That could be done on the basis of pre-existing clinical criteria or when a specialist erral had been arranged.

 If automation was not feasible, rely on non-physicians to trigger the decision-aid.  For example, office assistants could offer SDM to patients in the course of check-out.

Image from Wikipedia

Talk about a no win situation.  After seeing his "red line" go rudely unheeded, the President is facing the prospect of appearing weak if he does nothing or warmongering if he launches an attack.

Medical decision scientists ask: how did it come to this?

Mr. Obama is correctly admired for his "no-drama informed style of decision-making.  And good physicians, says medical science, should operate the same way.  According to this recent New England Journal article, consciously deliberative and logical approaches to diagnosis and treatment selection are far more reliable than the intuitive shoot-from-the-hip pattern recognition that used to rule the bedside.

Psychologists describe the latter as "Type 1" processing while the former is "Type 2."   Think George W. Bushs gut instincts over Iraqs weapons of mass destruction versus Barack Obamas disciplined rationality when he decided to attack the Bin Laden compound. He undoubtedly used the same methodology when he was pondering Syria.

But, thinks the Disease Management Care Blog, there are limits to brainy decision-making when the choices are overwhelmingly numerous.  In this retail business-oriented TEDTalk, Sheena Iyengar points out that dozens of options lead to procrastination followed by bad choices followed by low satisfaction. 

It can also apply to foreign policy. Given the vast array of pieces and potential moves on the Middle East chess board, little wonder that Mr. Obama would procrastinate for days saying he has "not made a decision," then apparently select an attack option disdained by even the New York Times and then engender even more second guessing by the very Congress that the President has repeatedly criticized as unreliable.

Ditto health care.  The downside to shared decision making is that an overwhelming number of testing and treatment options can lead befuddled patients to a "you decide, doc" mentality that leads the physician to regress to "Type 1" decision-making.

The DMCB isnt too sure how TEDTalks Dr. Iyengars suggested solutions can help the folks in the White House Situation Room, but the DMCB wonders if the national security staff shouldnt have done a better job of presenting the Commander in Chief with 1) a limited number of choices that were 2) more "concrete," as well as 3) arranged into categories with the 4) low complexity options offered first. 

That 4-fold approach could help docs and patients too.  The DMCB looks forward to additional research in the area.

In the meantime, there is one additional medical rule that has withstood the test of time that may also be useful in dealing with Syria. The DMCB offers it up to business and politicians alike: primum non nocere.

I have been inspired by the comments of a recent reader to get myself centered on my program again. Tricia and I have been sharing back and forth on the blog post just previous to this one and I must say that it really is nice to feel the power of partnership with her. It just seems so much richer to know that she is there, in the same boat that I am in, and we are not alone in our struggles. I desire for both of us to be successful. We share life-long weight problems, pre-diabetes, and the desire to make the kind of lifestyle changes that will help us rid ourselves of the diagnosis of "pre-diabetes." If you need to get back in the swing, please join us in stepping out on a ten-day getting started commitment.

My last official post was dated the day before Thanksgiving in November and I had plans to stay on track for Christmas and New Years, too... but somewhere things got foggy for me. Even my daily record has a few "missing days." But the past, is the past. I now must face forward and decide what my next step is.

The advice that I shared is the advice that I need. Here are the summary guidelines that I had come up with to get re-motivated and make a simple ten-day step in the right direction:

1. Read your book again for motivation.
2. Set a date to begin your change.
3. Prepare by removing what you dont need from your house
4. Prepare by providing what you do need for healthy eating
5. Do your plan for ten days
6. Then see where you are and decide what you will do for the next ten days.

1. Read your book again for motivation.

Many of us have been inspired by some book or program or idea that has helped us do the right stuff in the past, but we are no longer in that space right now. One way of getting back into that space of inspiration is to read the same book again. I did that a while back with the "Carbohydrate Addicts Lifespan Program." I was also very inspired by the "30 Day Diabetes Cure" with which I started this blog. I also have been inspired by and gleaned a lot of good information from the vegan culture that is very active on the internet (Ive shared about all this before.) 

If you know of a program that you were successful on, then go back, read it again, and begin to get your mind focused on the right stuff for you. Rekindle your passion. Get reacquainted with the guidelines you already know work for you. Allow yourself to be inspired.

2. Set a date to begin your change.

At some point, often while you are getting re-acquainted with the details, you will feel inspired to begin doing your program again. At that moment, set your date to begin doing the program. It is all well and good to read it... but you will only get results by doing it. Pick a date that is not too far away, but is far enough away that you can make the kinds of preparations that you need to make.

I know that when Ive been off my program for any length of time (be it weeks or be it years) it can seem overwhelming to even consider going back and doing it all again. It is "so much easier" to simply lolly-gag and continue stuffing all the standard stuff into my mouth while pretending that it does not make a difference what I eat. The point is, we begin to lie to ourselves. It is hard to admit that, but the addiction takes over and lulls me into "never-never land" -- you know -- the place where things never change?

Nothing can knock the block off the addiction lies like setting a date to begin. A starting date is concrete. It is a day on a calendar and no matter what your addiction says, that day will show up in your life. It is marching down the daily track in your direction. Your own personal day of reckoning will definitely arrive. If you can see it coming, that, all by itself, will motivate you to begin taking preparatory actions.

3. Prepare by removing what you dont need from your house

The most obvious first step is to get rid of all the stuff that you know you should not be eating, before your start date gets here. You will only make yourself sick if your method of getting rid of it is to eat it -- but this is your life and your choice. The better method of getting rid of stuff is to recognize it for what it is (toxic) and throw it into the trash. Do not leave even one spoonful of ice cream in your freezer. Simply wash it down the sink and toss the box out. You will be making space for the next step in the plan.

4. Prepare by providing what you do need for healthy eating

Using your program as a guideline, purchase the kinds of foods that you know will give your body health. Stock up on good healthy food. Some things will need to be divided into individual healthy meal portions and stored either in the freezer or the rigerator. These will be your new "convenience" foods.

In my case, that means that I need to purchase fresh raw vegetables and salad fixings. I also need to get good protein in the form of eggs, beef, pork, and chicken. Since I also have gout I need to be caul with animal protein (especially fish) but not extremely so. Ive been reading the book "Beating Gout" by Victor Konshin and have discovered that limiting animal proteins will only drop uric acid levels by two points at best, the rest must be done with medication. Ive been on the medication (Allopurinol) for about six months now and have not had a "flare" in quite some time. To me, this means that the guidelines Victor has given are working for me. Im going on Medicare on the first of March and when I get my new doctor (my old one does not take Medicare patients) and my new insurance, I will be having my uric acid levels checked to make sure Im on track.

I am going to be eating my food in the form that God gave it to me with my focus on raw vegetables and cooked meat. Im also toying with the idea of trying the "seventh-day cheat meal" as a standard procedure. I may use my next post, to describe that program in more detail. I have it written out for myself and may simply post it so others can see or use it also. It may be that I am not able to do that. I will find out, once and for all, if I can really do it. More on that another day.

5. Do your plan for ten days

I chose ten days because that is the time increment that was used in the "30 Day Diabetes Cure" and it really worked great for me. What I saw happening was that a ten-day span appeared to me to be a short do-able not-overwhelming time span. It was easy to think of doing something for only 10 days. The first challenge was to stop eating sugar of any kind, no sweets, and no sugar substitutes for 10 days. Then, once I accomplished that task, and saw how easy it really was, and how much better I felt, I simply continued.

Three days would not have been long enough to see the good results you would want. Three days is almost exactly the amount of time it takes to go through sugar withdrawals, so they are the hardest days to accomplish -- but since you have made a commitment, the first three days are done by having made the decision to do it. By day four, things begin to lighten up and you no longer even crave sugary items. From day four on, things get easier -- and they happen almost on their own. No will power is needed after day 4 because your body will no longer be pushing you. So... if you had only chosen to do the plan for three days, you would have shot yourself in the foot and not allowed the change to actually take affect in your body.  You would never have gotten to "easy street." After youve lived the results for ten days, it would be insanity to go back -- but the choice is still yours.

6. Then see where you are and decide what you will do for the next ten days.

By the time you finish the first 10 days the second 10 days will look really easy to accomplish. The hard part is over and the only thing you need to do is keep doing what you are already doing. But you have the option.  That option lets you be in charge of your own life. You decide what you will be doing next. And there it is: commitment -- and your "self" is fully engaged in the battle once again.

If you look at what has happened in your own life and you see a need to tweak something, now is your opportunity -- but do not let that interfere with your next step. Make any adjustments and then make your new commitment to continue on to bigger and better results.

Dont forget the "see where you are" part. On day 11 take stock and ask yourself some questions. Did your blood sugar numbers get better? (This also means that for the 10 days you did this, you kept track of your numbers.)  Did you lose any weight? How do you feel? Where are your pain levels? I have found in the past that my pain levels seem to greatly diminish on day 6. I dont know if other people experience the same thing, but if you do, you need to make a note of your pain levels before and after that initial ten-day accomplishment.

When you answer the above questions, and any others that are pertinent to you and your situation, you will be looking at concrete evidence of your own success. Nothing motivates like success!! Use your success to continue moving you along in the right direction.

Heres to DOING!! Let me know how you are doing!!

Be back soon,

Marcia

The Disease Management Care Blog recently attended a physician meeting that keynoted a U.S. Senator.  In his prepared comments, he admitted that he knew little about controlling health care costs.  Unfortunately, that didnt stop him from humbly paraphrasing the testimony of a famous economist:

"Find out what works," said the expert, "and do that."

Maybe some of the physicians silence that followed was an "aha!" reaction to the Senators insightful nostrum.  Some of it may have also been out of respect. 

The DMCB is sure, however, that most of the docs in the room were quietly thinking "You must be kidding me."

Such is the approach of the mandarins leading our federal health care institutions.  "Science and existing literature" says HHS Secretary Sebelius.  "Effectiveness" is the mantra of the Center for Medicare and Medicaid Innovation.  "Improving health care" is now part and parcel of CMS. 

Unfortunately, applying scientific evidence to the economics of health care delivery sounds easy enough until you get down into the weeds.  For a perfect example of that, consider the common condition of painful spinal stenosis among Medicare beneficiaries. According to this JAMA article, there were over 37,000 operations in this population at a national cost of $1.65 billion. 

Which begs the question: does spinal surgery "work," is "effective" and "improves health care?" Can the "science and existing literature" help us decide?

To get an idea of just how complicated the answer is, check out this Agency for Healthcare Research and Quality (AHRQ) research review on Spinal Fusion for Treating Painful Lumbar Degenerated Discs or Joints.  The conclusions from the abstract are:

Overall, limited evidence suggests that spinal fusion compared with physical therapy improves pain and function for adults undergoing fusion for low back pain due to disc degeneration. Because of insufficient reporting and variation in surgical methods used in the different studies, the incidence of adverse events (serious and minor) associated with fusion could not be determined conclusively. The evidence was insufficient to draw evidence-based conclusions for the benefits and harms of spinal fusion for patients with degenerative stenosis or degenerative spondylolisthesis of the lumbar spine. The evidence was also largely insufficient to draw conclusions about the benefits and harms of fusion compared with other invasive treatments or different fusion approaches or techniques.

In other words, there is some evidence that, compared to conservative treatment, surgery helps.  After that, its the stuff of caveats, statistics, evolving technique and myriad study limitations.

In fact, its so complicated that the only way it can be applied is by helping patients understand how the science applies to their unique circumstances and values.  Once the patient understands things, its a matter of letting that patient and doctor jointly decide on the best course of action.

That approach - in contrast to U.S. Senators musing on how we need a one-size-fits-all approach to what works - is called shared decision making and it can be applied to back surgery with considerable cost savings.

"What works?" asks the Senator?  The answer is for you to consider staying out of the way.

My first attempt at a video presentation.  Check it!  And head over to You Tube and "like" it.  And comment!

When it comes to cooking, theres no doubt about it: time is the chief obstacle to getting started. If you’re pressed for it, whipping up a three-course meal can seem as overwhelming as running a marathon in a bunny suit.

That’s why it pays to know some tricks. Some cheap tricks. Specifically, ten cheap tricks. (Note: not including this Cheap Trick, though they are also quite enjoyable.)

Some might find the following time-savers, like, “Oh, duh. I was born knowing this information. Get a job!” Others may be all like, “Oh, duh. I never thought of this. This is the most informative literature I’ve ever read, and that includes the ‘You’re a Woman Now’ pamphlet I got from my gym teachers in sixth grade.” Either way, they’re my story, and I’m sticking to em.

Readers, what did I miss? What are your easy shortcuts? Add ‘em in the comment section.

1) Wash fruit and veggies as soon as you get home from the supermarket.
It takes ten minutes and you can pick freely from your stash for the rest of the week. Don’t forget to dry the food completely, and include a paper towel in your storage vessel, perably lining the insides. This should extend the life of your produce by a few days, at least. And hey - if you want to chop, slice, or dice to prep for future dinners at the same time, more power to you.

2) Read the recipe (at least twice) beforehand.
Who here has been gotten all psyched up to make a delicious dinner at 6pm, only to find Step #4 takes two hours? (*raises hand*) Or that you’ve forgotten the tomatoes? (*raises both hands*) Or that you have no idea how to braise? (*raises both hands and foot*) Scanning the instructions can save you infinite failed meals, plus a few bucks on last-minute emergency purchases.

3) Set out all your ingredients before you begin to cook.
Not only does it make reaching for stuff much simpler, but it ensures you have all the ingredients on hand. If you want to measure and chop as well, go crazy. Chefs and Frenchy types call this “mise en place,” and it streamlines the whole cooking process. Pretty prep bowls (a la Alton Brown) can make it look professional, too.

4) Take care of long-cooking items (rice, roasted veggies) first.
When I first began cooking, one of my biggest problems was timing every dish so they finished together. The chicken was ready 15 minutes before the broccoli, and the rice wouldn’t be good to go for another half-hour. Nowadays, I take a minute or two to think of cooking intervals: What will take the longest? What can be prepared relatively quickly? Then, I get going on the food that requires the many-est roasting/braising/steaming minutes. Dinner doesn’t always time out perfectly, but at least we’re not eating in installments anymore.

5) Learn how to chop an onion.
Onions are the basis for … every dish, ever. In history. Seriously. I can’t think of an ingredient I use more frequently. And in the olden days, dicing one would cost me ten minutes and two Kleenex. Mincing one? Fuggedaboudit. Now that I know the correct technique, it takes less than 60 seconds. I’m much happier. So are my sinuses.

6) Do dishes as you go along.
Let’s face it: if recipes listed “Dish Washing Time” along with “Cooking Time” and “Prep Time,” they would practically double in duration. (30-Minute Meals – ha!) And for those of us without dishwashers, scrubbing plates, pots, and forks can take all the fun out of cooking. However: if you clean as you go along, you’ll reduce back-end soaping tremendously. (Maybe entirely, even.) And then your night can be your own again. (For Lost, presumably. Did you SEE last night? Husband-Elect has been in the fetal position ever since.)

7) Fear not the eyeball.
We’re using the Rachael Ray-approved definition of “eyeball” here, meaning: approximating ingredient measurements based on what they look like in your hand, rather than precise recipe quantities. As you cook more frequently, you’ll get a feeling for how much chili powder or olive you need. Even better, you’ll be better able to customize to your tastes. Of course, if you’d rather go by specifics…

8) Memorize measurements.
How many teaspoons are in a 1/4 cup? (Twelve.) How many cups are in a quart? (Four.) When a recipe calls for 2/3rd cup of flour, but you’re only making half a batch, how many tablespoons do you need? (A little less than six.) Knowing simple measurements by heart will make the scaling process go much faster. If this seems like too much to commit to memory…

9) Keep a calculator in the kitchen.
It could come in useful for a bunch o’ other things, anyway: estimating grocery bills, projecting portions, showing your roommates how much they owe you in back rent, etc.

10) Have a super-basic erence cookbook at the ready.
Whether it’s Betty Crocker or Better Homes and Gardens, owning a How To tome is invaluable. A good one will give you technique tutorials, cooking times and temperatures, measurements, substitutes, and plenty of pictures. And when you’re stuck, a quick flip-through will solve just about any problem.

BONUS
Get a garbage bowl.
Rachael Ray was right on this one, too; during your prep period, keep a large bowl at your side for scraps and garbage. It cuts down hugely on trips to the trash bin, plus a lot of leaning over. Great for people with bad backs and/or finite patience.

And that’s a wrap. Readers, the comment section awaits. Let’s compile the world’s greatest shortcut thread.

~~~

If you like this post, these might also delight you:

• Cheap Healthy Master Recipes: Eight Versatile Dishes Entirely Adaptable to Your Tastes
• Frugal Food Hacks: 10 Tricks to Simplifying Online Recipe Searches
• Overcoming Your Cooking Obstacles

As readers may recall, the Disease Management Care Blog is a big fan of shared decision making (SDM). Using unbiased, state-of-the-art and interactive media that presents a set of treatment options, patients with the help of their doctors are surprisingly able to input their values, make trade-offs and come up with the best choice. Research suggests that patients tend, in aggregate, to be both reasonable and conservative.

The DMCB is also a fan of the ePatient movement.  Based social media, this is the networked and two-way sharing of medical information in a virtual community of like-minded patients that also facilitates informed patient decision-making. Compared to SDM, ePatients have been less well studied, but there is some good research that suggests that these on-line communities are remarkably disciplined and accurate. In fact, advocates argue that ePatient communities, compared to physicians, are better able to alert its members about the latest medical updates.

Which makes the DMCB wonder if the ePatient movement represents a classic disruptive innovation that is threatening the SDM business model.  Commercial SDM typically is made up of video content (much like a DVD) that is developed by credentialed experts and has to be updated periodically. Contrast that approach with the ePatient community (on-line, on demand whenever you want it) that harnesses the wisdom of crowds and is so organic, it really never stops being updated.

Think music CDs vs. iTunes. Or DVD movies vs. on-line streaming.

But the most important distinction? The former is being sold by physicians or content developers, while the latter is being given away.

The DMCB speculates:

The shortage of primary care services, increased cost sharing, spreading consumerism, the explosion of medical information, distrust of authority, ease of use for social media, less concern about privacy, the rise of self-educated experts and a curious immunity from actually having to make money all make the DMCB think that the ePatient movement is here to stay.  Its value will trump the inevitable anecdotes of waylaid web users, e-mistakes and death by internet.

In order to stay relevant, commercial shared decision support tools will begin to direct users to medical e-communities. Physicians will "outsource" their own SDM to online ePatients. This will give IBMs Watson a run for its money. Architects of clinical guidelines, point of care decision support, EHR portals and health information exchanges will successfully ignore the ePatient movement - for now.

On-line bulletin boards will be the first stop for any new symptom and to second guess physician advice. The doctor-patient relationship will turn into a menage a trois.

"eApps" will appear for the persons with diabetes, mothers of leukemics and the children of persons with Alzheimers.

Health insurer perred provider networks will have one more reason to die off.

e-Communities will add value in helping its ePatients figure out how to get insurers to cover services that would otherwise be denied.

Some mainstream health organizations will host ePatient communities.  Authentic and trustworthy ones will learn from them. None will successfully commercialize them.

Researchers will tap into e-communities to recruit patients for research. The pooling of users data for observational research studies will grow.

Unfortunately, this will exacerbate the medical digital divide for persons without reliable access to the internet.

The love affair between U.S. residents and salt is making us sick: high sodium intake increases blood pressure, and leads to higher rates of heart attack and strokes. Nonetheless, Americans continue to ingest far higher amounts of sodium than those recommended by physicians and national guidelines.

A balanced review of the relevant literature has been published in the March 27, 2013 edition of The New England Journal of Medicine. Theodore A. Kotchen, M.D., professor of medicine (endocrinology), and associate dean for clinical research at the Medical College of Wisconsin, is the lead author of the article.

Dr. Kotchen cites correlations between blood pressure and salt intake in a number of different studies; typically, the causation between lowering salt intake and decreased levels of blood pressure occur in individuals who have been diagnosed with hypertension. Although not as pronounced, there is also a link between salt intake and blood pressure in non-hypertensive individuals. Additionally, recent studies have demonstrated that a reduced salt intake is associated with decreased cardiovascular disease and decreased mortality.

In national studies in Finland and Great Britain, instituting a national salt-reduction program led to decreased sodium intake. In Finland, the resulting decrease in systolic and diastolic blood pressures corresponded to a 75 – 80 percent decrease in death due to stroke and coronary heart disease. Neverthelesss, not all investigators concur with population-based recommendations to lower salt intake, and the reasons for this position are reviewed.

"Salt is essential for life, but it has been difficult to distinguish salt need from salt preference," said Dr. Kotchen. "Given the medical evidence, it seems that recommendations for reducing levels of salt consumption in the general population would be justifiable at this time." However, in terms of safety, the lower limit of salt consumption has not beeen clearly identified. In certain patient groups, less rigorous targets for salt reduction may be appropriate.

Written by the fabulous Leigh, Veggie Might is a weekly Thursday column about all things Vegetarian.

Fava beans have been haunting my dreams ever since the unfortunate Fava Bean Disaster of 2009. Every now and then, when it’s quiet and my thoughts turn to food, I find myself thinking about them and how I might redeem myself from such a fiasco.

On Sunday, I wandered into my local deli to pick up seltzer and something snacky to shove in my mouth while watching the Oscars. I aimlessly strolled the aisles until the smallish Middle Eastern foods section caught my attention. The deli owners hail from Yemen and keep two shelves at the back of the store stocked with beans and tahini.

I picked up a can of fava beans and made my way to the cash register. The clerk on duty, Khaled, who knows me and my preference for orange seltzer, looked at me with surprise when I put the can of fava beans on the counter.

“This is Arab food!” he said, smiling.

“I like Arab food,” I replied.

He laughed. “Do you know what to do?”

Jackpot! I thought.

“No, tell me.” I whipped a notebook and a pen from my bag and wrote down exactly what he said.

“Okay. Just oil, onion, garlic, tomato sauce, a half a tomato. Mix it all up. Wait. Mash beans first. But put in last.”

“Hang on a sec...,” I said. This was going to take some sorting. Then a man who’d been standing nearby chimed in. His name was Altef.

“Cook the onion and garlic. Then add the tomato sauce. Mix in the mashed beans,” he said.

“And some water,” Khaled interrupted. “Mix all together.”

“It sounds terrific.”

“Yes,” said Khaled. “Come back and tell me.”

We exchanged smiles and handshakes as the fava beans and I ventured out into the night.

Readers, you are third to know (CB was second) that I’ve finally had a fava bean victory! Like a Middle Eastern version of bean dip, this recipe makes a savory, tangy, garlicky spread for pita, crackers, or chips. Which is great for me, because chips and dip is CB’s second favorite food after pizza.

I made a couple changes to Khaled and Altef’s recipe. Since tomatoes are out of season, I substituted “tomato sauce and 1/2 tomato” for canned crushed tomatoes (what I had). A combination of diced or canned whole tomatoes and sauce would work great too. Once I combined all the ingredients per their instructions, I had a tasty bean mash that was a skosh flat. Lemon juice and parsley brightened it right up.

Except for the parsley—and the fava beans—this dish was made entirely of ingredients I had on hand. I think it would work with any mashable bean, and the stew is yummy with whole chick peas too, which I had for lunch today.

Fava Beans with Tomatoes was even better next day after the flavors had a chance to meld. CB and I had it along with the chick pea version, homemade hummus, steamed kale, and pita bread, for our own little at-home tapas meal. It would also be a welcome addition to the dip section of your next party spread. Just be sure to invite your new friends who gave you the recipe.

~~~~

If you fancied this recipe, you may also enjoy:

• Guacamole-Bean Dip Mash-up
• Tunisian-style Greens and Beans
• Pindi Chana

~~~

Fava Beans with Tomatoes
Serves 6
Inspired by Khaled and Altef at the 9th Ave. Deli


1 1/2 cup fava beans, mashed
16 ounces crushed tomatoes
2 teaspoons extra virgin olive oil
1 small onion, chopped
6 cloves garlic, minced
1 teaspoon salt
1 tablespoon pepper
1/4 cup water
1 tablespoon lemon juice
1 tablespoon parsley, chopped

1) Drain and rinse fava beans; then mash and set aside.

2) In a medium sauce pan, heat olive oil over medium heat. Saute onion and garlic until onion is soft, about 5 minutes. Add crushed tomatoes, salt, and pepper. Simmer for 5 more minutes.

3) Mix in mashed beans with 1/4 cup water (and chopped tomato, if in season). Cook for 10 to 15 minutes, stirring until thick. Take care; this stuff is splattery.

4) When the mixture is the consistency you like for bean dip, remove from heat and stir in lemon juice and chopped parsley.

5) Serve with warm pita bread as part of tapas spread with other small bites, like hummus, baba ghanouj, wilted greens, stewed chick peas and new friends.

Approximate Calories, Fat, Fiber, Protein, and Price per Serving
72 calories, 2g fat, 3g fiber, 4g protein, $0.42

Calculations
1 1/2 cup fava beans: 273 calories, 1.5g fat, 13.5g fiber, 21g protein, $0.98
16 ounces crushed tomatoes: 82 calories, 0g fat, 4g fiber, 4g protein, $0.99
2 teaspoons extra virgin olive oil: 79.2 calories, 9.24g fat, 0g fiber, 0g protein, $0.05
1 small onion: 20 calories, 0.1g fat, 0g fiber, 0g protein, $0.25
6 cloves garlic: 24 calories, 0g fat, 0g fiber, 0g protein, $0.07
1 teaspoon salt: negligible calories, fat, fiber, protein, $.02
1 tablespoon pepper: negligible calories, fat, fiber, protein, $.02
1 tablespoon lemon juice: 3 calories, 0g fat, 0g fiber, 0g protein, $0.06
1 tablespoon parsley: 1.3 calories, 0g fat, 0g fiber, 0g protein, $0.07
TOTALS: 429 calories, 11g fat, 17.5g fiber, 25g protein, $2.51
PER SERVING (TOTALS/6): 72 calories, 2g fat, 3g fiber, 4g protein, $0.42

Dr. Smith* was well known among the hospitals medical directors. Thanks to his superb training and busy clinical practice, this busy physician was convinced, thank you very much, that he had all the knowledge necessary to manage his patient population.

Summary quality reports, feedback and best practice advice he did not need.  He also loved pointing out that he wasnt being adequately reimbursed to deal with administrative hassles, many national Clinical Guidelines were based on faulty research, his patients were not "average," and his duty to his patients was to "first do no harm."  He believed in patient education but resented administrators meddling.

The medical directors werent about to use a "stick" and "de"credential Dr. Smith and kick him out of the network. The "carrot" financial P4P incentives they offered for quality measures were modest and comprised a only a small percentage of the physicians income.  They. Were. Stuck.

Enter the Affordable Care Acts Patient Centered Outcomes Research Institute (PCORI). Writing in the latest issue of Health Affairs, RAND researchers Justin Timble, Eric Schneider, Kristin Van Busum and Steven Fox reassure frustrated medical directors everywhere that PCORI will come to their rescue by ushering in a new dawn of clinical trial research.  The studies will be so good that Dr. Smith will change his passive-aggressive ways.

Dr. Timble et al point out that the reluctance of physicians like Dr. Smith to change their clinical practice is not surprising.  Payment mechanisms incent questionable treatments, much of the published medical science is riddled with ambiguities, even expert scientists succumb to a host of biases when they interpret study results and doctors are more interested in avoiding the risky downsides versus the upside benefit of new medical advances.  Last but not least, clinic-based electronic record decision support never fails to disappoint.

Fortunately, says these RAND authors, the PCORI is on it. Its sponsored research will transparently solicit stakeholder input and investigate all meaningful outcomes, including side effects.  When this high octane knowledge is combined with a dollop of rigorous guideline development, more gigabytes of information tech decision support and the luster of Obamacares payment reforms, uncooperative Dr. Smith will be transformed into compliant Dr. Smith.

Sounds good, but the DMCB doubts that sprinkling PCORI pixie dust on docs is the cure to what ails the health care system. In its estimation, the RAND authors and the editors of Health Affairs are only telling half the story.

The DMCB to the rescue.

Despite the authors enthusiasm, PCORIs well-meaning stakeholders will have to make real-world compromises on study scope, data collection and completeness. Their research methods and findings will never be completely immunized against healthy skepticism.  And while RAND scientists and the readers of Health Affairs are professionally invested in PCORI, how well it competes for the attention of practicing docs like Dr. Smith remains to be seen.

Financial carrots and sticks can be used to change physician behavior, but Dr. Smith will ultimately stay in the drivers seat thanks to a) a looming physician shortage and b) the prospect that total physician reimbursement will go down, leaving no room for incentives. While integrated delivery systems, accountable care organizations and physician-hospital alliances may (or maybe not) wring some dollars out of PCORI-based efficiency and quality studies, it remains to be seen how these big capital-intense organizations will share any precious leftover dollars with their docs.

The population health management (PHM) service community has a better answer.

While high quality research conducted under the supervision of an expert professional class has its place, they know its ultimately up to the informed patient to make decision.  A considerable body of research, much of which would pass PCORI muster, has shown that shared decision making using a personal physicians advice is remarkably adept at reconciling imperfect research with patient values and preferences.  This, in turn, increases quality and reduces unnecessary costs.

The DMCB has seen countless physicians like Dr. Smith welcome the help of team-based nurses who can help his patients. He may call it "education," but theyre engaging patients in science based decision-making and taking a lot of work off of Dr. Smiths hands.