Wake Up Your Mirror Neurons

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Listen with your eyes as well as your ears.”
-Graham Speechley

In the days before virtual visits and patients wearing masks, I would enter the exam room by greeting the patient, smiling and looking at them. So much information is communicated in this way. With our demeanor, we can convey caring, respect, and dignity. The patient, in turn, communicates mood, level of confidence, social/language/economic status, and (importantly) understanding.

My visits with patients are now either virtual (video or phone) or in-person with both provider and patient wearing a mask to prevent potential COVID transmission. This is affecting my ability to assess the patient’s mood and understanding, and makes it harder to quickly gain the trust of new patients.

Neuro-psychology experiments show that many human interactions (including social learning, empathy, and transfer of emotions) depend on the Mirror Neuron System of the brain. This system works best when a person experiences more complex sensory input. For example, a 2-dimensional view of a face on a video screen is less effective at influencing the Mirror Neuron System than an in-person interaction, where body posture, body motion, and context add meaning. The greater activation of the Mirror Neuron System when we are in the presence of others helps explain the excitement we now feel with interacting in-person with friends and colleagues, compared to previous video interactions.

The Mirror Neuron System also rapidly and unconsciously allows us to interpret the emotional state of others based on facial expressions. The eyes and the mouth are most expressive, so covering the mouth with a mask to prevent disease transmission decreases the information available to our Mirror Neuron System.

In many health care settings, routine mask wearing is still required. How can we make up for the loss of ability to see the facial expressions of the mouth? Interviews of women in countries where face coverings are common for religious reasons suggest three compensatory mechanisms that we can learn.

Eyes: First, learn to communicate emotion more effectively with our eyes. This takes a bit of practice. It requires us to spend a little more effort making eye contact and intentionality in connecting eye expression with emotional status.

Non-facial body language: Gait, character of a handshake, posture, and use of hand expressions can convey much emotional context. Clothing and grooming contain additional clues. These are difficult to see over video visits, but can be very helpful for in-person visits where the patient is masked.

Voice: Verbal expressiveness can convey information lost when visual cues are not present. This can be more subtle, depending on language concordance, personalities and habits of the clinician and their patient. I have seen a few clinicians who have remarkable natural capacity to strongly connect with patients, even on phone visits. Most of us can learn to master our greeting of patients on phone or video visits to build a sense of trust and empathy. As the clinician starts thinking about the differential diagnosis, options for testing, how many patients are waiting, and any personal stressors, our verbal expressiveness may lose some of its empathic quality.

For an excellent and very readable review of the many ways we communicate non-verbally, see The Power of Body Language, by Tonya Reiman.

For leaders and managers engaging with co-workers and community partners, these same compensatory mechanisms can be used for virtual interactions, but at a price. The level of engagement from virtual conferences and meetings is often significantly compromised, resulting in less interactive dialogue, less productive debate, and less synergistic learning. In particular, partners and policymakers are not cooperating and solving problems as effectively. To overcome this, we must strive to leverage in-person interactions. If infection safety is a concern, we can meet outdoors (particularly good for meetings with a meal) or in a well ventilated indoor setting with sufficient distance to minimize risk of airborne infection but close enough to see each other’s expressions and body language. Judicious use of rapid COVID antigen tests also has a role.

This is our new normal. We owe it to our patients, our organizations and ourselves to put our Mirror Neuron Systems back to work.

Moving Forward

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The pessimist complains about the wind. The optimist expects it to change. The leader adjusts the sail.”

-John Maxwell

The COVID pandemic was a storm that caused not only loss of life and disability, but tremendous lasting stress to the health care delivery and public health systems. Since March, the storm is settling down, and we seem to be beginning a prolonged recovery phase. Staffing shortages, financial stresses, and anxiety about COVID, the economy and world events are major headwinds to this recovery. These headwinds are diverting leadership energy away from collaboration, innovation, and quality improvement activities.

It is possible to move forward against headwinds. Sailboats do this by trimming their sails, and carefully navigating their boat to a heading as close as possible to directly into the wind, and then changing tack periodically so that the net movement can be directly into the wind. The skipper (leader) needs to pay close attention to the wind, communicating quickly with a crew that knows they need to work together to achieve their goal.

Mastering the headwinds

As clinical leaders, I hope you are in a phase in this pandemic recovery in which you can trim the sails, and refocus your teams on moving forward with performance improvement and collaboration activities. Our teams at Partnership HealthPlan of California (PHC) are here to support you in this effort.

Use and Misuse of “Evidence Based”

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

People almost invariably arrive at their beliefs not on the basis of proof but on the basis of what they find attractive.”

-Blaise Pascal

Clinicians strive to base our diagnostic and treatment practices on appropriate interpretation of scientific studies. The Evidence Based Medicine (EBM) movement has grown in the past 50 years to help create frameworks for evaluation and application of such studies. The worthy goals of EBM are to avoid unnecessary interventions that can potentially harm patients, and improving the health care that we do provide.

The term “evidence based” is sometimes misused.

I recall a resident physician from UCSF, commenting on a particular intervention: “there is no good evidence that this intervention works.” In this case, however, there was no strong evidence for any other intervention, including the one used at UCSF. The resident earlier had pointed to previous studies that showed both a lack of statistical improvement with an intervention, and a “trend towards benefit.”

On the other hand, a study can be done that shows that an intervention has no benefit. These two situations are not equivalent. “Lack of evidence of benefit” is not the same as “evidence that an intervention does not work.”

In the first case, a clinician can very defensibly try out the intervention if there is not established superior treatment. In the second case, when studies definitively show no benefit, a clinician would arguably be practicing substandard medicine to use the particular intervention.

Evidence based medicine was also misused several times in the Covid-19 pandemic. Transmission of earlier Coronaviruses causing SARS-1 and MERS was found to be impeded by use of masks. Early in the Covid-19 pandemic, before studies could have been conducted proving that use of masks also reduced transmission, the Center for Disease Control and Prevention (CDC) stated that mask wearing by the public was not recommended, because of the absence of evidence that masks helped. It incorrectly implied that absence of evidence of benefit meant that there was no benefit, even though the prior probability based on related viruses suggested that a benefit was likely. When the evidence became available and the message flipped to recommend masks and later highly effective masks to prevent transmission, this fundamental change in recommendation contributed to lack of trust in the CDC.

In behavioral health and social science research, the “evidence-based practice” is a standard requirement for programs to be funded. For example, an academic study of a new behavioral counseling technique might show that it reduces depression symptoms by 5%, from an average PHQ9 score of 20 to 19. Technically, this is evidence based—a published study showing a benefit of this intervention. Many government grants would allow this intervention to be implemented more widely.

Implementing this “evidence-based” intervention would be a mistake, for two reasons:

First, the setting that this academic study was done almost certainly differs from any real-world setting. “Implementation science” studies such questions. In general, four different replications of a behavioral intervention in different settings all with a similar benefit are needed to have a 95% or greater confidence than another implementation of this intervention will also have the same benefit.

Second, although the 5% reduction may be statistically significant, is it not clinically meaningful. Sadly, one often has to read scientific studies carefully to see if a difference is clinically meaningful.

The term “evidence based” has also been used to disparage a person’s educational level. For example, a community health worker (CHW) with at 10th grade education may be intuitively skilled at connecting with clients and getting them to change behavior yet lose a job to a more educated and articulate applicant if the hiring manager, instead of recognizing that the CHW has not been trained on “evidence-based approaches,” says that the CHW does not use such approaches. This statement is arguably a reflection of implicit bias against someone with less formal education.

All of these examples of misuse of “evidence based” are a reflection of cognitive biases of one form or another. In the first case, the resident preferred one approach over another and incorrectly used the term “evidence based” to disparage one approach and prop up another. This is sometimes called the “confirmation bias” or the “my side” bias, a very common and very human bias to which scientists are not immune. In the second case, many Asian countries commented on the bias against public mask wearing in the United States, which likely played a role in the early recommendation to NOT wear masks to limit the spread of Covid-19. In the third case, the confirmation bias is also at play, because the researcher really wants something important to come out of their research, as this more often leads to publication of studies, invitations to give talks, and academic reputation.

When someone smart uses “evidence based” to promote or disparage a particular practice or treatment, our internal bias-detection should move into high gear. Switch to system 2 thinking (slow thinking), and critically review the underlying evidence for statistical significance, clinical meaningfulness, and replicability.

Just Fix It

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation.”

-Dr. Rudolf Virchow

Paul Farmer, MD PhD, an infectious disease specialist and anthropologist who started a foundation to provide care to impoverished populations in Haiti and around the world, died suddenly of an apparent heart attack this past week, at age 62.

Dr. Farmer studied Haitian culture as a medical anthropologist before becoming a physician and a specialist in infectious diseases. Through his direct patient care activities and by developing a public health infrastructure in a remote area of central Haiti, he cultivated a deep understanding of the links between disease, poverty, and political power. He wrote several books on this topic, using patients’ experiences to drive home his arguments.

Biographer John Tracy Kidder in “Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man who Would Cure the World,” relates this story:

A TB patient from a village hadn’t shown up for his monthly doctor’s appointment. So—this was one of the rules—someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because “noncompliant” patients didn’t take all their medications. Farmer said, “The only non-compliant people are physicians. If the patient doesn’t get better (because they don’t take medications as prescribed), it’s your own fault. Fix it.”

Of the many moving and interesting parts of Farmer’s life detailed in the book, this one sticks with me, because it is so at odds with how many of us think about “non-compliant” patients. Attributing failure of an intervention to non-compliance is a way for health care professionals to assign responsibility or blame to our patients for them not getting better, because they don’t follow our scientific advice. The alternative term “non-adherence” was initially used with an intent to look for underlying factors that could be impacted, but it has come to be used in place of “non-compliant” just to sound less judgmental, but with the same implicit intent and outcome. The clinician moves on to their next task, their next patient.

Dr. Farmer believed that an understanding of a patient’s culture is essential to build trust between the physician and the patient allowing a skilled physician to devise a way to form an alliance with the patient that will lead them, long after they feel better, to complete an antibiotic treatment for tuberculosis, to cure them of the infection. This is difficult work in many ways. It requires time spent listening to the patient, as well as mental creativity, and tenacity.

This belief is what drove Dr. Farmer, a handful of Haitian doctors, a larger group of community health workers, and the community health center/hospital he ran in Haiti, to uncompromisingly provide quality health care to an impoverished population about the size of Shasta County. No one in the region served by his health center had died of measles or tuberculosis in many years (unlike other areas of Haiti, where deaths from these diseases were sadly common).

Dr. Farmer said his role model, since his undergraduate years, was Dr. Rudolf Virchow, a 19th century German physician of many skills and interests. Dr. Virchow was known as both the father of modern pathology (with an understanding of the central role of cells in tissues and diseases), and also the father of the field of social medicine. Like Farmer, Virchow was an anthropologist and a scientist as well as a prolific writer on both scientific and socio-political topics.

The work that you do in your health centers and offices follows the same spirit of service to the most vulnerable members of our community. Let Farmer and Virchow inspire us to not accept mediocrity, bureaucratic barriers, or blame our patients for poor outcomes. We must develop a deep understanding of the cultures of the patients we serve, the system we are working within, and combine this with compassionate medical care to meet the challenge of caring for the individual patients before us.

Improving Diagnostic Judgment: A Behavioral Economic Approach (Part IV in series on Diagnostic Accuracy)

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“We’re blind to our blindness. We have very little idea of how little we know. We’re not designed to know how little we know.”

-Daniel Kahneman, Nobel Laureate in Economics

Regular readers of this newsletter will recall a series of lead articles on improving diagnostic accuracy (Parts I, II, and III found on our phcprimarycare.org blog). Medical schools, residencies and continuing medical education programs have recently adopted some formal training in critical thinking, including how to understand how cognitive biases can lead to mistaken diagnoses. This takes the principles of behavioral economics, based on the pioneering work of Psychologist Daniel Kahneman (summarized for a general audience in his most famous book, Thinking Fast and Slow), and helps us understand how physicians think and make mistakes.

In the January 25, 2022 JAMA, Dr. Pat Croskerry provided a succinct summary of recommendations for overcoming these biases to become a “rational diagnostician.”

  1. Establish Awareness of How Cognition Works. Understand the most common cognitive biases and the difference between type 1 (intuitive/fast) and type 2 (analytical/slow) processing.
  2. Teach and Coach Critical Thinking. Excellent coaching promotes deep learning, allowing 10-fold faster development of expertise. Understanding the mechanism of deep learning can help those of us without ready coaches to improve our mastery of complex areas of expertise. The book The Talent Code, provides the best overview of this topic.
  3. Make the Work Environment More Conducive to Sound Thinking. Three main conditions that interfere with analytical thinking include:
    1. Psychological stress leading to anxiety and dysphoria,
    2. Sleep deprivation causing chronic fatigue, and
    3. Excessive cognitive loading (responding to a barrage of emails and tasks without time to pause and reflect).
  4. Circumvent Type 1 Distortion. Setting up mental steps and processes to allow “executive override” to pause and reflect on the possibility that our intuitive initial impression is incorrect, and evaluating possible alternative explanations or decisions. For example, when a patient’s clinical presentation has some findings that are not explained by our initial, presumptive diagnosis, we pause to consider what else might explain this. For example: “Is this recurrent pharyngitis a sign of an underlying immune compromise?”
  5. Expand Individual Expertise. While routine expertise is developed with training and practice, adaptive expertise encourages flexibility and innovation in problem-solving. Adaptive expertise is fueled by curiosity; it develops when exploring the possibilities raised with type 2 thinking, and also by regularly reading journal articles or exploring topics that are unrelated to any particular patient.
  6. Promote Team Cognition. Regular conferring with colleagues on challenging diagnostic or therapeutic situations brings a collective expertise to bear, which can produce better outcomes for your patients. While synchronous consultation (for example “curbside consultation”) allows some back and forth, and is quicker, asynchronous consultation (for example using eConsult or secure email) allows time for more nuance and detail to be included and more analytic thinking and background research to be done.
  7. Mitigate Judgment and Decision-making Fatigue. Dr. Croskerry suggests the use of “cognitive forcing strategies,” like adopting clinical maxims such as “rule out worst-case scenario,” practices such as routinely documenting a differential diagnosis, or always using a pre-operative checklist.

The common feature of these approaches is that they will require an intentionality derived from a sense of professionalism. It is essential for clinical leaders to find ways nurture these habits for those on our teams.

Principles of Improving Diagnostic Accuracy (Part II of Diagnostic Accuracy Series)

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“There are three constants in life: change, choice and principles.” –Steven Covey

Steven Covey notes that actions and intent flow from principles; they are the foundation used to choose between different courses of action and to decide where to invest energy in self-improvement. The importance of principles extends to specific fields as well, including medicine.

In Part I of this series, we reviewed the extent of diagnostic inaccuracy in medicine, ranging from an error rate of 5% to 50%, depending on the nature of the patient/problem. A key contributor to this inaccuracy is our way of thinking about uncertainty: we are trained to be overconfident in the accuracy of our decisions.

Unfortunately, the other extreme, excessive concern about diagnostic uncertainty, leads less confident clinicians to order excessive laboratory and radiological tests. The Choosing Wisely campaign begins to shine a light on the scenarios where such tests are unequivocally useless but does not provide a framework for unnecessary testing when there is even slight uncertainty.

Last year, the American College of Physicians convened a group of experienced clinicians, teachers, and communications experts to address this challenge of diagnostic uncertainty. The product of this effort is called, “Ten Principles for More Conservative, Care-full Diagnosis.” Here is a brief summary of the first five principles:

  1. Promoting Enhanced Care and Listening. Perform an appropriate and thoughtful history and physical exam. When the diagnosis is unclear, continue collecting the history and evaluating changes in the physical exam at subsequent visits to determine how the patient’s clinical course is unfolding.
  2. Understand Uncertainty. Become comfortable with it, learn how to respond to it, and how to convey it to patients.
  3. Respond Carefully to Symptoms. Balance the natural history of common symptoms (75% – 80% of self, resolve within 4 to 12 weeks) with a consideration of potential psychological causes of symptoms (2/3 of patients with anxiety, depression, or somatoform disorders are undiagnosed), considering both the Social Influencers of Health and the long-term effects of Adverse Childhood Events, which also cause or accentuate symptoms.
  4. Maximize Continuity and Trust. Continuity of care by a primary care clinician is not only the single best predictor of patient satisfaction but also generates the trust needed to address the psychosocial issues mentioned above and to have patients trust the strategy of “watchful waiting” to observe the natural history of symptoms.
  5. Taming the Time Pressures around Patient Visits. Ensure the clinician has adequate time to listen, observe, discuss, and think. Adjust the system and the environment of care, as needed, to support this.

The derivation of these principles, which perhaps seems self-evident, required thought and effort of experts; trying to improve without guiding principles to guide us is disjointed at best. Like moral philosophy, it is the application of principles which is more challenging. Some approaches include taking time to think about how to apply these principles, finding small self-improvements or system changes to move towards achieving them, and telling stories to help reinforce how we approach gaps.

You, as clinical leaders in your settings, have an especially important role to play in helping your clinicians learn and apply these principles. On behalf of your patients, thanks for addressing these challenges in your setting.

Diagnostic Accuracy (Part I in a series)

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm, which defined 6 realms of quality:

  • Safe
  • Effective
  • Patient Centered
  • Timely
  • Efficient
  • Equitable

Most quality improvement and quality assurance activities related to health care address one or more of these realms.  However there is one critical area that is missing from both the IOM realms and most QI plans.  This missing realm is at the heart of what it means to be a clinician, is infrequently measured and is uncomfortable to verbalize.

This realm is Accuracy, in particular the diagnostic accuracy of clinicians.

Diagnostic Inaccuracy:  Studies show that between 5 and 50% of diagnoses are erroneous, depending on the type of patient/problem.  The low range applies to a population of patients where most are normal; the high range applies to a population where all patients have complex abnormalities.  Autopsy studies and studies with “secret shopper” patients show rates of inaccuracy of between 10 to 20%.  (Mark Graber:  “The Incidence of Diagnostic Error in Medicine”, BMJ October 2013)

What is the source of this diagnostic inaccuracy?

At the core is an insufficient appreciation of uncertainty.  Put another way, clinicians and scientists are often overconfident in the accuracy of their decisions.  This psychological trait develops when we are trainees, as it makes us appear confident in the eyes of our patients, and helps prevent us from being paralyzed by indecision.  Fortunately, many medical conditions in primary care resolve on their own, so neither the clinician nor the patient ever become aware of the inaccuracy.

We can reduce diagnostic inaccuracy by changing the way that we think.

Daniel Kahneman (winner of the 2002 Nobel Prize in Economics) describes two ways of thinking:

  1. Fast thinking (also known as intuitive thinking or system I thinking)
  2. Slow thinking (also known as rational thinking or system II thinking)

Fast, intuitive thinking tends to be automatic, with input from emotions.  In his book, Thinking Fast and Slow, Dr. Kahneman notes 12 different classes of bias and 5 heuristics which can lead to irrational decisions, when we think intuitively.

Slow, rational thinking is more deliberative, systematic, and logical, with an evaluation of consequences of a decision.

As we go through our everyday lives and routine practice of medicine, we use fast thinking for most decisions, so we can get through our days without being paralyzed by indecision over minor decisions.  When the stakes are high, or when we notice a diagnostic pattern that doesn’t quite fit, we need to transition to slow, rational thinking.  For a clinician to be efficient and accurate, we need to know when to toggle back and forth between slow and fast thinking.

When slow thinking is associated with a retrospective analysis of a serious diagnostic error, as happens in morbidity and mortality rounds, or when a clinician becomes aware of a diagnostic error that occurred, it is good to explicitly think about which biases or heuristics contributed to the error, to help prompt us to move to slow thinking when needed.

This process is sometimes called “cognitive debiasing,” which is a fancy way of saying “learning from our mistakes”.

2022: Endemic COVID-19 and Preparing for COVID-2x

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The value of experience is not in seeing much, but in seeing wisely.”

-William Olser

What does our future look like with COVID-19 becoming endemic? While vaccines and “natural” infections give some temporary immune protection from infection and re-infection, our collective immune system memories may render these infections less severe as time goes on, but this protection will be less for those who are older or immune compromised. Like influenza, regular COVID vaccine (possibly annual) will be recommended to slow spread of the infection (for healthier people), and make infections less deadly (for those with medical conditions rendering them more susceptible).

This has happened before. Paleo epidemiologists suspect that the “Russian flu” pandemic of 1889 to 1891 was actually caused by a coronavirus, possibly the grandfather of one of the subtypes that currently causes seasonal cold symptoms. Because modern DNA sequencing did not exist in the 19th century, we cannot be sure.

For this current Omicron outbreak, our system is strained, so there is a risk that too many people will let down their guards prematurely, increasing hospitalizations to a degree that forces dangerous staffing patterns, and before new powerful treatments like Paxlovid can become more widely available.

COVID-19 will become endemic, which will not make it benign. Omicron is more infectious than influenza and cold viruses, and immunity to coronaviruses if proving very transient. In the H1N1 outbreak of 2009 killed over 12,000 Americans, the majority under age 65. Hospitals were very full, but not as strained as by COVID in 2021. A massive immunization campaign resulted in just 20% of the population being vaccinated, enough vaccination with natural immunity to keep H1N1 at lower levels in subsequent years. However, the R0 of H1N1 was just 1.5, compared to about 4 for Omicron in the UK where vaccination was relatively high. Seasonal vaccination rates in the United States will not be enough to prevent annual waves of seasonally mutated COVID-19 in the years to come. We may get more used to them, but they will be worse than annual influenza seasons, at least for 2022, and maybe for years to come.

In the end, our annual winter “flu” season, which is actually caused by a collection of flu-like respiratory viruses, will be a more severe each winter, as COVID-19 joins influenza, RSV, parainfluenza, rhinovirus, the other four coronaviruses that cause milder respiratory infections, and others in causing illness and hospitalization each winter. The summer waves we saw the last two years are likely to continue, to some degree, as well.

Quarantines for COVID-19 will be phased out, but some amount of voluntary isolation of those that are ill will persist, and there will be a high usage of masks to prevent spread of respiratory pathogens in the next several years.  Virtual visits will continue to be a significant part of our health care delivery.

There will be other new coronavirus infections in the future. Now is a good time to prepare for the next coronavirus that jumps species.

In the 21st century, COVID-19 is the third coronavirus to appear that causes severe respiratory symptoms (after SARS-1 and MERS). Given the huge reservoir of viruses in other species, we are quite likely to have a Coronavirus infection caused by a different strain sometime in the next decade, a COVID-2x epidemic that could lead to another pandemic. Looking at the shortages we had early in this pandemic, we can prepare for COVID-2x, as well as more severe influenza outbreaks. There are lessons for industry, government, public health authorities, and the general public. Here are some that might be most helpful for clinical leaders in primary care:

  • Ensure local community stockpiles of highly effective masks such as N-95s are ready –enough to last for a couple of months. Encourage patients to keep some on hand as well, for future winter “flu” seasons and future pandemics. Don’t let them all expire at once, set up a system for regular purchase and replenishment.
  • Gather together and organize policies, procedures and leadership lessons, and find a way to go through these systematically each year, so the knowledge is refreshed as staff change. Include not just best practices, but also any mistakes made and options for responding to the most challenging parts of a pandemic.

Transition community connections that were forged in the COVID-19 pandemic to work on other important health issues. Set up regular meetings with your local health officer to work together on shared priorities. Relationships will be key to rapidly and effectively responding to future public health needs.


Not all Charity is Equal

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“No one has ever become poor by giving.”

-Anne Frank

Twenty years ago when I was the Medical Director of Community Health Clinic Ole in Napa, someone I still don’t know placed one hundred $50 gift cards to a grocery store in my home mailbox, with a note, saying that I should distribute them to needy patients of our Health Center. Our outreach team mobilized and distributed them to 50 particularly needy individual patients and families. The same thing happened the following year. The anonymous donor trusted me to make sure that their charity would go to a person who needed it; that person would never know who gave this gift, because even I did not know who it was. The charity was given without the desire or expectation of being recognized publicly, or even privately.

Eight years ago, a retired businessman –who came to the United States from India to build a business selling medical supplies—lent a 17 year old young man from his hometown in India the money to be able to attend UC Davis where he was accepted as an undergraduate aerospace engineering student. The young man’s family was of modest means; they could not afford to send him abroad to be educated. The retired businessman was not related to the family, but he made this high-risk personal loan to help him achieve his dream to be a high-tech engineer, and to support his family in the process. This young man met my daughter and is now my son-in-law.

Around this time of year, many people call local homeless shelters offering to help. Thanksgiving dinner at the Napa homeless shelter was purchased, cooked, and served by the local painters union. They called and volunteered to do this, without being asked.
All of these are examples of the highest level of charity. About 950 years ago, a physician-philosopher named Maimonides identified eight levels of charity. Paraphrasing them in order from highest to lowest:

  1. The greatest level: Support a member of your community with a gift, a loan, or helping find employment to strengthen his hand so that he will not need to be dependent on others. This is the charity provided by the Indian businessman.
  2. Give to the poor without knowing to whom one gives, and without the recipient knowing from whom he received it. It is given in secret to a trustworthy intermediary. This is the charity of my unknown neighbor, who provided the gift cards for my patients. Leaving a generous tip for the low-income housekeeping staff at a hotel could fit in this category, as well.
  3. Give to someone that is known to the donor, but the recipient does not know who gave the gift.
  4. Provide a donation when the donor does not know who they are helping, but the recipient does know.
  5. Give directly to someone, with both the donor and recipient knowing each other, but the gift is given without being asked. The painters who prepared and served Thanksgiving dinner to the homeless of Napa would fit in one of these three levels (3, 4, or 5); although the donor and recipient could see each other, they did not know each other’s names.
  6. Giving to a poor person after being asked.
  7. Giving inadequately, but gladly and with a smile.
  8. The lowest level of charity is to give unwillingly.

In the progressively lower levels of charity, much of the purpose of the charity is to be seen by others as being charitable (called virtue signaling by psychologists). This charity is still very important, as many U.S. charitable organizations rely on these lower levels to gather donations. In the higher levels, the charity is not intended to improve one’s social capital but rather aims to increase the opportunities of others and positively impact communities.

Here are three takeaways for each of us:

  1. Contemplate these eight levels of charity; talk them over with your family and friends.
  2. This holiday season think about ways you can give at one of the higher levels.
  3. Let humility guide your giving practices. Celebrate those who quietly, give without expecting recognition.


Back to the Future: Refocusing on Prevention and Chronic Disease Care

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only way you can stay on top is to remember to touch bottom and get back to basics.”

-Shane Black (Director, Screenwriter, Actor)

The COVID pandemic has had a number of ripple effects on the health of your patients, beyond the consequences of infection and stress-induced exacerbation of mental health status. Many clinical quality metrics saw plummeting performances in the past two years. For example, the proportion of those with a diagnosis of hypertension whose blood pressure is controlled dropped by over 10%. A major driver is decreased in-office visits where blood pressure is checked, with a relatively small proportion of patients using home BP monitors to follow their own blood pressure. Drops in well-child visits, breast, and cervical cancer screening are other examples.

The summer wave of the delta variant of COVID-19 led to increased infection rates, staffing disruptions, and new vaccination recommendations. It is becoming clear that COVID is so infectious and the level of protection from infection conferred by the initial vaccination series and prior infection is transient, so it will not be disappearing but rather become an endemic disease for the foreseeable future.

With this in mind, it is a good time to remind ourselves of other health issues facing the patients we serve, issues that were often deferred by patients and clinicians in the midst of the waves of pandemic cases. They include core preventive activities, like screening for breast and cervical cancer, use of nicotine products, and misuse of alcohol and other drugs. They include control of chronic conditions like hypertension, diabetes, asthma, and COPD.

In the next couple of months, we encourage you to pause, take a breath, and start to think about how you will re-engage your organization with these important core preventive and chronic disease activities!