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Although I know relatively little about Zeo, I was sorry to hear this.

Why? Because insomnia complaints are a big problem in primary care, and something I’ve struggled with often as a clinician. (I’ve also personally been plagued by severe insomnia at certain times of my life.)

In fact, I would say that insomnia falls right in the space where I can see consumer digital health technologies helping us the most. That’s because this condition:

• Is a common complaint in primary care. This study found that 69% of primary care patients experience insomnia. It certainly is a complaint that I hear about often from patients (although it often comes up as a “by the way” at the very end).

• Is linked to adverse health outcomes. Insomnia is associated all kinds of problems. Diminished quality of life, decreased work performance, and increased mood disorders have been noted in research. Research has also linked insomnia with developing Alzheimer’s.

• Requires data on the symptom to effectively evaluate and treat. The proper evaluation of an insomnia complaint should not only include a history and examination — one should evaluate for an underlying/co-existing physical or mood disorder — but also requires good information on what exactly is going on with the person’s sleep. Is the problem with falling asleep or staying asleep? Every night or a few times a week? How many hours per night is the person sleeping? And of course, once an attempt is made to treat insomnia, clinician and patient will need to determine whether the insomnia is improving.

• Should be treated non-pharmacologically rather than via prescription drugs. Research has shown that behavioral approaches such as cognitive-behavioral therapy, relaxation therapy, stimulus control, improved sleep hygiene are overall safer and can be more effective than the use of sedatives. Just about every medication which makes people sleepy, such as Ambien, tends to worsen balance and cognition, and can be habit-forming. (Furthermore, recent research confirmed that older adults who use benzodiazepines — a class of sedatives often prescribed for sleep complaints — developed dementia at higher rates. Here’s a cool JAMA study on using cognitive-behavioral therapy to treat insomnia in older adults.)

• Is currently inadequately managed by primary care as usual. Although insomnia is a common issue for primary care patients, we often do a poor job managing it. Most clinicians don’t have the time or inclination to take a careful sleep history and guide patients through a comprehensive sleep improvement plan. Instead, we tend to prescribe sedatives and often never get around to following up. This means many patients end up on sedatives long-term, and the older ones in particular end up at considerable risk of adverse consequences.

In short, insomnia is a common medical complaint that many primary care providers could use help managing more effectively. And much of the evaluation and management is relatively non-medical: we need sleep diaries and other methods to get accurate data on a person’s sleep, and we need help encouraging patients to implement lifestyle changes and supporting behavioral therapies.

A doctor tries to manage her own insomnia

There’s nothing quite like suffering from a health problem to provide insights on how one might help patients with something similar.

As I mentioned above, I’ve at times suffered from pretty bad insomnia. In the fall of 2011, I was having a terrible time. I was very stressed out by my job as a medical director and PCP, and found myself unable to get enough sleep at night. I’d toss and turn for 1-3 hours every night before lapsing into fitful sleep. I felt tired and irritable most days. And I was especially frustrated by my inability to fall asleep easily: there I was with *so* much work to do and it was killing me that I couldn’t get the sleep I needed.

Like most working physicians/mothers, I didn’t have time to go see my own doctor. I figured she would just recommend the usual sleep hygiene tips, and I didn’t need her to prescribe Ambien since we already had some in the house.

Then one weekend a non-physician friend mentioned his own struggles with insomnia, and recommended a workbook written by a sleep therapist.

This I found immensely helpful. Even though none of the information was truly revelatory to me, it was terrific to see a comprehensive, effective approach spelled out in plain English, along with specific actions to take.

Of course, the author strongly recommended sleep logging, and cautioned the readers against depending on sedatives long-term.

How to log my sleep? I found an app for my smartphone and started to use that. It was so-so (sorry, can’t even remember the name) but certainly better than logging on paper or on my laptop. I also started to try to implement some of the relaxation and cognitive retraining strategies. (It’s important to try to unwind before bedtime, and one must really try to avoid anxiously lying there in bed trying to fall asleep.)

Based on my experience with the workbook, I started recommending it to patients. Although my older patients often had pain or other physical problems contributing to their sleep issues, most could also benefit from the strategies in the book. (Plus, it explained sleep logging and provided templates!) I also suggested it to some of our licensed clinical social workers, who were seeing some patients for behavioral therapy related to insomnia. They found it helpful as a tool to support the work they were doing with patients.

In the end, although my sleep improved somewhat through logging and behavioral changes, what really helped me turn the corner was deciding to leave the job. (Not sure I’d recommend an app try to help people in this manner.)

Still, this experience reinforced two key points to me:

1. Behavioral and lifestyle approaches greatly benefit from symptom tracking and logging.
2. A behavioral/lifestyle approach can be challenging to implement on one’s own.

Couldn’t digital health technologies help us with the above?

What I would’ve told Zeo

I’m a physician and in the business of responding to patients’ health concerns, and of managing multiple chronic conditions.

So if Zeo had sat me down and said “We have this consumer technology that tracks how people sleep,” I would’ve said “Great! Patients complain to me about sleep all the time! And I have so much trouble getting people to track their sleep symptoms. But I need them to do it in order to evaluate the problem, and see if treatment is helping.”

The thing is, as best I can tell, Zeo did not fundamentally conceive of themselves as a company in the business of equipping patients to effectively get better care from clinicians.

Instead, here’s their mission statement:

“The Company’s mission is to help people discover new, science-based ways to lead more an active and healthy lifestyle by taking control of the awesome and restorative power of sleep.”

In other words, Zeo was part of the quantified self movement.

Whereas what countless patients could use would be a quantify-the-problem and engage effectively with the healthcare system movement.

Now, I can see why consumer health companies might be a little leery of getting involved in the patient-clinician encounter. I imagine they are worried about having to appeal to physicians, about whether the device will have to be medically regulated, about liability, about clinical proof that the device provides a medical benefit, and about whether they’ll have to try to get the device paid for by insurance, etc.  All reasonable concerns.

Still, I feel I can envision opportunities for companies such as Zeo, to help with problems like insomnia. Why can’t companies serve consumers by:

• Helping them track symptoms. In this case, it’s providing the sleep log.

• Helping them identify and summarize valuable pre-visit history. Is it practicing medicine to tell a person that if they want to ask their doctor about sleep issues, here are the questions they should be ready to answer? (i.e. How long has it been going on? How much does it affect daytime functioning? Any pain, cough, shortness of breath, etc at night.) I would be so happy as a PCP if patients could access a sensible pre-visit insomnia questionnaire before bringing a problem to my attention. Would make my life easier!

• Suggest proven non-pharmacological alternatives to discuss with the doctor. Let’s face it, doctors tend to prescribe pills. It’s fast, it’s what we’re used to doing, plus pharma keeps spending money encouraging us to do it. Why not help equip patients to politely remind physicians to consider alternatives?

• Support implementation of proven lifestyle interventions. In this case, it could be something like providing the user with support in implementing relaxation exercises, and reminders regarding good sleep hygiene.

What clinical studies would I need to use something like this with my patients?

My main concern would be regarding the validity of the tracking tool. A smartphone based log is just like people writing things in a notebook: you take their word for it and hope they were reasonably accurate.

For a physiological tracker, like Zeo’s headband, I’d want to know how well its sleep assessment corresponds with other technologies often used in clinical medicine, like actigraphy and polysomnography. (Am just noticing that Zeo currently has such info here.) This information should be easy to find on the company’s website, and should summarize the results of validation studies in nice easy-to-read English. (Don’t just plunk the abstract there; get a health writer to reformulate. Everyone, including doctors, prefers to not read scholarese.)

Otherwise, if the device proposes pre-visit questions that are in line with what expert articles say are the key history elements — best if these articles are tailored toward a PCP’s initial eval of a complaint; which is a different standard than an expert specialist evaluating a complaint — I wouldn’t expect clinical studies. After all, these questions are meant to be an aid to a successful clinical encounter, not a substitute or a form of medical therapy in of themselves.

In other words, I would’ve told Zeo to make sure it’s easy for clinicians to trust the data provided by the device, and I would’ve encouraged Zeo to focus on equipping patients to track their symptoms and constructively preparing for visits.

But all this is just, of course, one practicing doctor’s opinion, and I have no idea how viable a business proposition this would’ve been.

What I do know is that in primary care, we sure need help helping patients with insomnia. So I hope future companies will build on Zeo’s strengths and bring us some assistance soon.

Summing it up

Insomnia is the kind of primary care concern that a consumer health tech company like Zeo could’ve eventually helped me with. It’s a common complaint with significant health consequences.  It’s a problem that really benefits from a data diary. And it’s a problem that often should be treated via lifestyle/behavior changes, rather than through prescription drugs.

Patients and clinicians need tools that support better clinical management of common primary care problems. Rather than focus on the wellness/fitness market, consumer health companies may want to consider ways in which they can support better clinical care. There are surely opportunities to do this by helping consumers track data for certain common health concerns (such as insomnia), and by helping people better prepare for clinical visits related to these concerns.

Consumer health technologies could also serve patients by equipping them to ask doctors about evidence-based, non-pharmacological management of conditions such as insomnia.

[This post was first published on The Health Care Blog on 3/8/13, titled “What Will Tomorrow’s Doctor Look Like?“

“What does the 21st Century Physician look like?”

Lisa Fields (@PracticalWisdom) cc’ed me on a tweet about this; it’s the featured question at www.tomorrowsdoctor.org, an organization founded by three young professionals who spoke at TEDMED last year.

I’ll admit that the question on the face of it struck me as a bit
absurd, especially when juxtaposed with the term “tomorrow’s doctor.”

Tomorrow’s doctor needs to be doing a much better job of dealing with
today’s medical challenges, because they will all be still here
tomorrow. (Duh!) And the day after tomorrow.

(As for the 21st century in general, given the speed at which things
are changing around us, seems hard to predict what we’ll be doing by
2050. I think it’s likely that we’ll still end up needing to take care
of elderly people with physical and cognitive limitations but I
sincerely hope medication management won’t still be a big problem. That I
do expect technology to solve.)

After looking at the related Huffington Post piece,
however, I realized that this trio really seems to be thinking about
how medical education should be changed and improved. In which case, I
kind of think they should change their organization’s name to “Next
Decade’s Doctor,” but I can see how that perhaps might not sound catchy
enough.

Linguistic choices aside, there’s an
important issue here, and it keeps coming to mind as I follow the trends
in healthcare innovation:

How far ahead should we look as we try to apply creative energy to solve important problems?

I say let’s be careful about how far ahead we look. After all, there is more than enough to keep us busy today, and tomorrow.

For instance, I take care of complex patients now, and I know that
there will be people very much like my patients around for the next
20-30 years, if not for longer. This is part of why I don’t have much
patience for the tendency of the innovators to emphasize “prevention”
and a nifty tech future in which technology changes behavior so that
people don’t develop all these pesky chronic illnesses which
characterize the “sickcare system.”

It’s not that prevention isn’t important, or that we couldn’t face a radically different healthcare landscape in 20 years.

Rather, it’s that it slightly kills me that so much of this
creativity and intelligence and innovation keeps leapfrogging over the
very important — and very interesting — problems facing healthcare’s
power users, and these are problems that we need to solve by TOMORROW.
Or the day after. Or maybe the year after, but really, if they don’t get
meaningfully addressed within the next several years, we are going to
have even worse problems than we have now.

And yes, a key subset of those problems that need solving is how to
equip physicians to step up to the challenges at hand. (All clinicians
need equipping, but because of their historic status and role in
healthcare, the case of physicians requires special attention.)

So let’s think about it: what do we need doctors to be able to do by tomorrow?

What Tomorrow’s Doctor Should Be Able To Do

I’m going to talk literally about tomorrow, in that these are all
things that ideally docs would be able to do today. Here’s how I would
start my list:

• Be comfortable with the e-patients.
This means being comfortable with patients who are engaged, equipped,
and empowered, often because they are accessing resources outside the
traditional healthcare system (i.e. online patient communities, journal
articles, etc). Not all patients are e-patients, but many are and we
should expect this to become much more common. Patients will also
increasingly be reading their notes, a la OpenNotes.

o In practical terms, this means docs should be
comfortable with patients who ask a lot of questions, and should be
prepared to explain their recommendations. Unfortunately, many docs are
not so comfortable with this, in part because it’s a cultural shift in
the clinician-patient relationship, and in part because of systemic
hindrances, like visit times that are way too short to address
everything that should be addressed.

• Engage in shared decision-making.
Rather than just tell patients what to do (or what we think they should
do), we should really be engaging patients and families in working out a
plan. This means we need to be able to present options, counsel
patients on the expected benefits and risks, solicit input from patients
regarding preferences and values, and otherwise effectively collaborate
in how we move forward with patients’ health.

o In practical terms, this means doctors need get better
at presenting expected benefits and risks (technology could help make
the data easier to have at hand), and doctors need the communication
skills to have these conversations with patients.
o Some would even say that many doctors need a complete attitude
adjustment, and I suppose this is true. Still, more constructive to
focus on a few key skills that we can ask doctors to work on.

• Be able to coordinate and cooperate with other clinicians. The
days in which a single doc was PCP and followed patients into the
hospital are gone, even though some heroic clinicians still manage to
provide this continuity of care. Medicine now requires doctors to work
effectively with many other clinicians (not to mention the teams which
are becoming increasingly common with primary care offices).

o In practice, this means that docs need to:
   
– Document so that other people can figure out how to follow-up and synergize. This is a big change for many docs.
    
– Read other people’s notes, and incorporate into their own activity.
Also a big change for some docs. For instance, when I was at the VA, I
noticed that many specialists were not reading my primary care notes,
even though they were easily available.
    
– Appreciate that other clinicians, including non-docs, have an important role to play in the patient’s care.

• Be comfortable with continuous quality improvement (CQI) and PDSA cycles.
Many doctors are far too used to their practices remaining fairly
static, barring the introduction of new drugs here and there. In fact,
not only do we need to improve things, but we should really expect that a
regular part of our work will be reviewing and improving our personal
practice.

o Doctors should be familiar with such on-the-ground quality improvement techniques such CQI and plan-do-study-act. Of course, we need to develop better measures and we’ll need capable guidance on PDSA cycles,
but in general, all practicing physicians should be familiar with the
basic methods by which we can review our practice and improve it.

o Doctors should be used to constructively participating in these
activities on a regular basis. Having tried to herd physicians into
doing this, I’d say it should really be a weekly activity.

• Be comfortable learning new ways of practice.
There is learning to tweak and improve what you’re already doing (see
above), and then there is learning a whole different approach or method
of doing your work (like learning to do your work with an EHR, or no
longer having to fit work within face-to-face visits, or adapting to
team-based primary care). Medicine is changing, and even though I really
don’t know what it will look like in 10-20 years, clearly we docs must
be prepared and willing to rethink how we apply our knowledge and skills
in the service of helping people with their health.

o Periodic changes in the way we practice should be expected. Just as the kitchen staff at the Cheesecake Factory (read Atul Gawande’s New Yorker piece
if you haven’t yet) expects to learn to make several new dishes twice a
year, doctors should expect to change the way the practice regularly
(though hopefully not every six months).
o On the other hand, someone will have to invest time and resources in
these upgrades (it’s a seven week process for the Cheesecake
factory)…the current climate in which we expect docs to update on the
fly because it’s better for society and patients — and because we’re
throwing some incentive money at them — is really not realistic.

• Be comfortable with well-designed technology. Not
only do we all need to be able to type, but we’ll need to all be fairly
comfortable using technology, because more and more of it will be
involved in healthcare.

We could of course come up with more key competencies, and also the
skills needed to be proficient in the above, but I’ll stop there for
now.

Incidentally, although I think we need the skills above tomorrow, I also suspect they’ll all be useful in 2050.

The medical education effort we really need

The truth is that although we certainly should revise and improve the
medical school curriculum, the people who are most in need of a medical
education effort are our estimated 950,000 practicing physicians.

Why? Because many of them are expected to continue practicing for
decades, because their actions currently drive much of what isn’t
working well in medicine (although heaven knows much of that is the
crazy system around us), and because we really can’t make healthcare
better without changing what physicians do and how they feel about it.

Furthermore, although the effort to change medical school education
is laudable, medical students are profoundly influenced and shaped by
what is modeled by the practicing physicians around them.

How can we help practicing physicians develop these new skills and behaviors?

I haven’t yet seen any large scale proposals that seem viable,
although I’m sure we could learn a lot from Kaiser and other larger
organizations that have experience shaping physician behavior. Certainly
a little CME credit or incentive money won’t cut it, but what will? If
you have ideas, I’d love to hear them. (I myself am very interested in
tapping physicians’ intrinsic motivation, but am not sure how one would
operationalize into a large-scale change effort; change is hard!)

Summing it up

Tomorrow’s doctors need to have the skills to deal with today’s most
pressing healthcare problems, because today’s problems — including
helping people with multiple chronic diseases — are not going away any
time soon.

Specific skills that we all need to develop ASAP as physicians
include becoming comfortable with e-patients, with shared
decision-making, with continuously reviewing and revising our practices,
with using technology, and with meaningfully collaborating with other
clinicians (and with patients and families). We also need to prepare
ourselves to periodically substantially revise the way we deploy our
skills in the service of the healthcare system.

The highest priority for this education effort should be today’s
practicing physicians, rather than the medical trainees. Although
medical trainees also need to prepare for the healthcare system of
tomorrow, it’s the actions of today’s practicing doctors that exert
incredible influence on the healthcare system, and powerfully influence
medical students.