How Are Those New Year’s Resolutions Holding Up?

How Are Those New Year’s Resolutions Holding Up?

Don’t Give Up On Your New Year’s Resolution!

 
Tips: The first ingredient to success is to set goals that are realistic and achievable. They must be not only humanly possible, but also logistically feasible. Does it fit in the schedule? How long is the drive?

Next, add a pinch of joy. Goals should be enjoyable, not simply chores to be tackled because it’s the right thing to do.

Third, build support. Is the ohana on board? Solid support, whether it is a weight-loss challenge among co-workers, a workout partner or a skillful coach, is huge. I’ve been doing martial arts in the evening for many years. My family believes it keeps me sane. Although I know I am missed, the support is there. Finally, set a combination of short-term and long-term goals.

Here are some suggestions for the Wealth of Health:

Watch the mouth:

 
No amount of exercise will make up for a consistently unhealthy diet, especially in the absence of portion control. Start with those green vegetables and, if unaccustomed to fresh salads and raw greens, steam them lightly, Be sure to consume lean protein regularly, and easy on the carbs. Go for local, organic and non-GMO. If possible, get to the farmers market and make eye contact with the person who grew the food you will eat. Pick a vice and cut it back. Give up some sodas, smokes or a scoop of rice. Consider setting some goals about what comes out of the mouth as well. Negative chatter can be incredibly habitual. It has the potential to put us in the position of victims or victimizers and tends to detract from our mental health and human relationships and has no upside in business. The people I know well who make it a practice of not talking stink, regardless of the situation, seem to live in a better place. Still, there is no replacement for straight talk or for sharing what we truly feel. Suppression breeds illness as well.

Don’t forget, the mouth and nose are also for breathing. Notice that when we are angry or fearful, we tend not to exhale fully. Likewise, when people are emotionally down, their inhalation tends to be shallow. Consider taking five minutes each day to sit and reflect on the breath. Just notice the pattern. Guaranteed, this will cultivate the wealth of health.

Move the body:

 
When Americans think exercise we think “cardio” and “resistance” training. For cardio the best case is to get the heart rate up with a good sweat six days per week. Twenty minutes three times per week is the minimum. If you are overweight or over 40 and have not done much exercise, first get medical clearance to avoid a heart attack out of the gates. For resistance training, most people think weights, which is fine if the technique is solid. Swimming is terrific especially for those who, because of joint problems, need a low-impact activity.

Flexibility training is the essential third leg of the exercise tripod. Most of us spend a few minutes limbering up before a run or a weightlifting session but don’t take the flexibility training as seriously. It deserves equal time. Yoga is hard to beat if taught by a well-trained teacher, and almost anyone can enjoy it. Be more cautious with the big yoga chains that have commoditized the ancient art. Yoga is especially important for those who play sports that use one arm or that require the body to twist in the same direction each time such as golf, tennis or baseball. Manakai o Malama continuously sees joint injuries and sprains among those who have omitted flexibility training for too long. The determined streak that drives us to keep breaking our personal records for time or weight is a blast, but there comes a time in life when it is more important to stay physically healthy and pain-free for the long run. We see countless people in the clinic who, if they could go back in time, would let go of the personal record, to avoid lifelong pain or disability.

Cultivate the mind: Perspective is everything. I like to fish. It struck me once after pulling a big bull mahi onboard that for one person catching a fish is a legal way to kill, while the next person is harvesting a sacred life to feed the family. OK. Maybe most guys are, like, just fishing. The point is that perspective is everything, but there is a tendency to be so habituated, so close to it that we fail to recognize what really drives our actions. Taking just a few minutes each day to reflect, observe and reaffirm our New Year’s resolutions is worth a million bucks.

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Get Fit For The New Year 2019!

Get Fit For The New Year 2019!

What’s Your 2019 New Year’s Resolution Hawaii?

 
Tips: The first ingredient to success is to set goals that are realistic and achievable. They must be not only humanly possible, but also logistically feasible. Does it fit in the schedule? How long is the drive?

Next, add a pinch of joy. Goals should be enjoyable, not simply chores to be tackled because it’s the right thing to do.

Third, build support. Is the ohana on board? Solid support, whether it is a weight-loss challenge among co-workers, a workout partner or a skillful coach, is huge. I’ve been doing martial arts in the evening for many years. My family believes it keeps me sane. Although I know I am missed, the support is there. Finally, set a combination of short-term and long-term goals.

Here are some suggestions for the Wealth of Health:

Watch the mouth: No amount of exercise will make up for a consistently unhealthy diet, especially in the absence of portion control. Start with those green vegetables and, if unaccustomed to fresh salads and raw greens, steam them lightly, Be sure to consume lean protein regularly, and easy on the carbs. Go for local, organic and non-GMO. If possible, get to the farmers market and make eye contact with the person who grew the food you will eat. Pick a vice and cut it back. Give up some sodas, smokes or a scoop of rice. Consider setting some goals about what comes out of the mouth as well. Negative chatter can be incredibly habitual. It has the potential to put us in the position of victims or victimizers and tends to detract from our mental health and human relationships and has no upside in business. The people I know well who make it a practice of not talking stink, regardless of the situation, seem to live in a better place. Still, there is no replacement for straight talk or for sharing what we truly feel. Suppression breeds illness as well.

Don’t forget, the mouth and nose are also for breathing. Notice that when we are angry or fearful, we tend not to exhale fully. Likewise, when people are emotionally down, their inhalation tends to be shallow. Consider taking five minutes each day to sit and reflect on the breath. Just notice the pattern. Guaranteed, this will cultivate the wealth of health.

Move the body: When Americans think exercise we think “cardio” and “resistance” training. For cardio the best case is to get the heart rate up with a good sweat six days per week. Twenty minutes three times per week is the minimum. If you are overweight or over 40 and have not done much exercise, first get medical clearance to avoid a heart attack out of the gates. For resistance training, most people think weights, which is fine if the technique is solid. Swimming is terrific especially for those who, because of joint problems, need a low-impact activity.

Flexibility training is the essential third leg of the exercise tripod. Most of us spend a few minutes limbering up before a run or a weightlifting session but don’t take the flexibility training as seriously. It deserves equal time. Yoga is hard to beat if taught by a well-trained teacher, and almost anyone can enjoy it. Be more cautious with the big yoga chains that have commoditized the ancient art. Yoga is especially important for those who play sports that use one arm or that require the body to twist in the same direction each time such as golf, tennis or baseball. Manakai o Malama continuously sees joint injuries and sprains among those who have omitted flexibility training for too long. The determined streak that drives us to keep breaking our personal records for time or weight is a blast, but there comes a time in life when it is more important to stay physically healthy and pain-free for the long run. We see countless people in the clinic who, if they could go back in time, would let go of the personal record, to avoid lifelong pain or disability.

Saving Our Planet 2019

Saving Our Planet 2019

December 21, 2018

Among the landmark issues affecting the health of the blue planet in 2019 is whether the fracking boom will be leveraged to develop sustainable energy resources for the long run. The trajectory of climate change depends on it. The ability of the United States to increase oil production by approximately 1 million barrels per day during the past several years — causing it now to exceed the production of Russia and even Saudi Arabia — has given an economic boon to the nation, dropped the price of oil and reshuffled geopolitical priorities. This window of opportunity must be put to good use.

As the United States rapidly approaches energy independence, the critical, strategic role once played by the Middle East as a source of crude oil has waned. OPEC’s recent decision to maintain production levels allowing oil prices to slide was motivated by the fact that cheap oil will improve global demand and modestly slow increases in the rate of U.S. production year on year.

OPEC’s alternative — to drop production and raise prices in the near term — would only have accelerated the increase in American oil production and resulted in both reduced global demand and a smaller market share for OPEC. The debate is how low prices can go before fracking becomes unprofitable.

Although it costs more than simple drilling, technology continues to improve. There is a range in the cost of production depending on geology, the quality of what is being extracted and distance from distribution networks. However, even in North Dakota’s Bakken shale region, by some estimates, the break-even point is now under $42 per barrel.

In addition to crude oil, fracking also produces immense volumes of natural gas. When burned, natural gas is cleaner and releases fewer greenhouse gases but it is still not a sustainable fuel and, like crude, is still a cause of global warming. The fracking process uses large amounts of fresh water and often occurs in places where the water table is limited. When mixed with chemicals to crack open the earth’s crust, it also carries the possibility of contaminating groundwater deep beneath the surface. The potential for geological instability is a further concern.

The two principle beneficiaries of cheap oil are the U.S. and, especially, China. By contrast, Venezuela, Iran and Russia are among the most vulnerable. A sustained, severe drop in oil prices could result in substantial instability that is hard to predict.

In any case, progress toward international agreement on global reduction of greenhouse emissions is moving ahead slowly. As part of an agreement with Xi Jinping of China in November, President Obama announced that the United States would emit 26 to 28 percent less carbon in 2025 compared with 2005 levels. In turn, China pledged to reach peak carbon emissions no later than 2030 by investing in clean energy sources, like solar power and windmills, that would account for 20 percent of China’s total energy production by that time.

The United Nations Climate Change Conference last month in Lima resulted in modest incremental progress, but the greatest challenge continues to be the divide between wealthy, developed nations and the more populous developing economies.

The next one will be held in Paris this year. The conference objective is to achieve a legally binding and universal agreement on climate, from every nation. A tall order.

Back at home an early debate is heating up on the proposed $4.3 billion acquisition of Hawaiian Electric Industries by NextEra. The press release reads, “Nation’s leading clean energy company to support Hawaii in achieving a more affordable clean energy future,” but some are not so sure.

In any case, the respite in oil prices and America’s fast-approaching energy independence is an opportunity to transition to more affordable, sustainable and renewable energy. It must not be squandered. Profits must be directed toward research and development and robust government incentives that result in a smarter, smaller carbon footprint.

Ballooning Cost Of Dementia Goes Beyond Dollars & Cents

Ballooning Cost Of Dementia Goes Beyond Dollars & Cents

If dementia were a country, it would be the world’s 21st-largest economy, ranking between Poland and Saudi Arabia, according to the Alzheimer’s Association. The global annual cost of care for 2010 was estimated to be $604 billion. About one-third of those dollars, $203 billion, was spent in the U.S., and that number is expected to increase quickly. Current projections place the tab at $1.2 trillion by 2050 for the United States alone.

This week the Group of Eight (G-8) agreed to elevate its commitment to fight Alzheimer’s disease, a principal cause of dementia, by finding a cure. The call to action was reminiscent of when the G-8 determined it would address the AIDS epidemic years ago. The problem is that, like AIDS, there is no established cure. Pharmaceuticals work for only a portion of patients and only for a limited period of time. Britain led the way in promising to double its expenditure on research, spurring other G-8 ministers to follow.

The population of people with dementia is rapidly expanding. Currently, 5.2 million Americans suffer from Alzheimer’s disease, making it the sixth leading cause of death in the U.S. As death from other major diseases slowly decreases, for dementia the numbers are up, with a 68 percent increase in the past decade. By 2050, 13.8 million Americans are expected to suffer from Alzheimer’s disease.

Arguably even more important than the financial burden is dementia’s mental and emotional burden. Many patients suffering from dementia experience depression and anxiety. The same can be said for their daily caregivers. A recent report of the Alzheimer’s Association showed that family and friends invested more than 17.5 billion hours of unpaid care in 2012. Sixty percent of them rated the emotional stress of caregiving as “very high,” and one-third reported symptoms of depression.

At the same time, we live in a society where we believe that “who we are” is limited to “what we think.” Popular literature reflects this opinion with best-sellers like “We Are Our Brains.” As a consequence, losing cognitive function and memory becomes synonymous with losing oneself. People around those with dementia will express that the old him or her no longer exists. As a result “Alzheimer’s” becomes one’s new identity. That comes with a profound sense of loss. One patient described it as a funeral spread out over several years.

In Western society the brain seems to be valued most among the body organs, but this view is not shared everywhere. In traditional Chinese medicine (TCM), for example, the kidneys are considered the “root of life.” They are believed to hold the genetic blueprint of who we are. A good functioning kidney, according to TCM, will cause a person to thrive by stimulating growth and development, fertility and gentle aging. In Tibetan medicine the stomach is considered the prime organ, as it purifies all nutrients and energy flows before entering the body. A strong stomach is associated with a long and healthy life, whereas a weak stomach predisposes a person to many ailments. In both traditional Chinese and Tibetan medicine, the brain is more incidental.

What can we do to protect our brains from this malady? Research has shown that an active brain is less likely to develop dementia. Many doctors encourage their elderly patients to read, play crossword puzzles and sudoku. Certain types of meditation and yoga may be even more powerful. Harvard researchers have shown that mindfulness-based stress reduction therapy consisting of a combination of meditation and yoga is able to slow the onset of Alzheimer’s disease in patients with mild cognitive impairments. Although the findings are preliminary, the possibilities are exciting. Not only does it give patients in early stages of the disease a sense of control, meditation and yoga can also help reduce the mental burden of the disease.

The benefits of meditation and yoga apply not only to those who suffer from dementia. Too often we spend our days running around without taking the time to rejuvenate and reflect, making peace of mind appear elusive. As it turns out, being totally present in the moment may be the best investment to prevent dementia later in life.

Inaccurate Calorie Counting Will Keep The Pounds On

Inaccurate Calorie Counting Will Keep The Pounds On

 
Accountants are sometimes disparagingly called “bean counters,” but the truth is that counting beans is much like counting money. Body weight is the result of calories consumed minus calories burned just as net income is revenue less expenses. The calories we put in our mouth are used up by both our basal metabolism and physical activity. Any excess gets stored as fat while a deficit burns up the stores, resulting in weight loss. The bottom line is that 3,500 calories equals 1 pound. Accountants and health care providers will argue that it’s not so simple. Fair enough; consider this a “bare bones” explanation.

To employ a lifestyle that ensures a healthy weight, it is essential to drill down and understand the details of a caloric profit and loss statement. Countless patients complain to their health care providers that they watch what they eat and get plenty of exercise but can’t seem to take off the extra pounds. Once the provider determines through laboratory testing that there is no medical reason for weight gain, such as an underactive thyroid, the therapeutic relationship can reach an uncomfortable impasse.

Failure to lose excess weight in the face of a reasonably healthy diet and regular exercise often comes from overestimating how many calories are burned by physical activity and underestimating how many calories are in those little tasty rewards for good behavior. To lose 1 pound per week, one simply needs to reduce their steady-state intake by 500 calories per day. Here are some foods that can be left off the table to get there: two Spam musubi (506 calories), 1 cup of macaroni/ potato salad (509 calories), 1 cup of oxtail soup (458 calories), one lau lau (414 calories) or one Big Mac (550 calories).

In contrast, calories burned during a given activity depend on one’s current weight, height, age, gender and other individual characteristics. Still, the average person burns about the same amount of energy while watching television as when sleeping and only slightly more when sitting at a desk. Roughly 500 calories are burned during a decent night’s sleep. On the other end of the spectrum, scuba diving can burn as much as 900 calories per hour depending on how cold the water is, while moving along on a stand-up paddleboard will average roughly 500 per hour. Swimming draws roughly the same as does mountain biking or a strong-paced hike up Koko Head. Yoga can also burn up to 500 calories per hour when practiced full tilt.

While diet and physical activity are both essential to maintaining a healthy weight, to pay for one slip of the tongue can take a huge physical effort. Unless you are fully ready to hustle up Koko Head right after lunch, don’t eat that second lau lau. Let it slide only a few times and be ready to carry around an extra pound next time you take the hike. Call my CPA if you don’t believe me.

Happy Thanksgiving!

Happy Thanksgiving

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Curbing Obesity

Curbing Obesity

Ira Zunin, M.D., M.P.H.

Medical Director of Manakai O Malama

  

While in Hong Kong, I once stood at a busy intersection waiting for the light. A Chinese woman walked up, peered into a cage of full of chickens and quickly pointed to one. The attendant reached in, pulled out the chicken and with a meat cleaver promptly removed its head. He tossed the chicken into a barrel of boiling water. In no time he pulled it back out, plucked it, carved it and rolled it inside a scrap of newspaper. The lady tossed a few coins into the man’s palm. He handed her the package, and she quickly joined me in the crosswalk as the light changed.

Traditional Chinese value food still teeming with life. In contrast, public health education has taught Americans that food is fuel and to consume specific amounts of recommended nutrients. Fast food changed all that. Now, Chinese and Americans suffer from obesity at alarming rates.

Obesity worries the Congressional Budget Office, which sees the problem as one of gripping importance to the economy. In a recent brief the CBO reported that:

» From 1987 to 2007 the fraction of overweight adults increased to 63 percent from 44 percent while the share of obese adults more than doubled to 28 percent from 13 percent.

» Health care spending per capita for obese adults exceeded that for normal adults by 8 percent in 1987 and 38 percent in 2007.

» If obesity continues to rise at its current rate, health care spending for all adults will rise to $7,760 in 2020 from $4,550 in 2007.

How do we trim pounds and dollars? Consider Slow Food, a global association founded in Italy to stem the tide of mindless calories from fast food and the “disappearance of local food traditions and people’s dwindling interest in the food they eat, where it comes from, how it tastes and how our food choices affect the rest of the world.” There is a huge difference between a piece of fruit grown on a giant farm on the mainland and sent by container ship compared with one grown on the islands and sold to you with a smile by the local farmer in one of our farmers markets.

Michelle Obama set a wonderful example for the urban population when she planted a vegetable garden with inner-city children on the White House grounds. In its first year the garden harvested an estimated 1,000 pounds of produce, which was shared with homeless people and United Nations diplomats alike.

We’re told that Oahu’s population is too large to achieve self-sufficient food production. Perhaps, but we can certainly do better. My family decided to pull out the ornamental plants on our modest bit of aina and plans to optimize the space for an edible garden. If you live in an apartment or condo, consider joining a community garden.

Edible schoolyards can make a big difference in the way children develop their relationship to the earth and to the food they eat. To plant a seed, tend a garden and enjoy the harvest is an experience that will be remembered for a lifetime. To bring that harvest into the home, cook a meal and share it with loved ones will leave a child forever changed.

When I care for an obese patient, we usually try to agree on one doable change at a time: hold the soda, curb the fries or katsu, only one scoop rice. This approach often enables people to shed some easy pounds. But durable change will only come about when we, as a culture, shift our relationship to the food we eat by cultivating an interest in how it is grown and where it comes from. Remember to take time in life to prepare and share healthy meals with people you care about.

  

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Physician Burnout

Physician Burnout

Ira Zunin, M.D., M.P.H., M.B.A

Medical Director of Manakai O Malama

  

In Sept of this year, a local medical association invited me to speak about the mounting problem of physician burnout, its causes and possible remedies. Hawaii is already struggling to solve a severe, ongoing physician shortage. Why are they burning out, and what can be done to prevent our doctors from running for the door?

In speaking with physician colleagues, their most common complaints are declining reimbursements amid increased operating costs. In addition to changing payment schemes from carriers, there are also more time-intensive burdens for documentation.

In addition, it is increasingly difficult to obtain authorization for testing and treatment. In a recent meeting with one of Hawaii’s largest emergency departments, physicians complained that because of increased efforts required to gain approval for an MRI, patients are now being sent to the emergency department just to get the study. While this relieves pressure in the outpatient office, it takes up resources better spent on true emergencies, and it obviously adds to the cost of care.

Using information technology, patients are also better informed, which is a benefit to self-advocacy but also results in increased demands for care that are not always medically justified.

Concerns regarding liability and medical malpractice continue today as they have for quite some time. Added to this are worries that a very small fraction of disgruntled patients can now easily cause a negative splash on social media damaging a hard-earned good reputation.

Uncertainty about the future is also unsettling. Obamacare, a beneficial yet still imperfect system, has been under fire for the past two years. While efforts to repeal and replace the Affordable Care Act have failed repeatedly, the ACA has been systematically weakened as its provisions are cut or modified. Health care is in such a state of flux that physicians are concerned about their ability to properly care for their patients.

The rapidly changing landscape has caused a great deal of industry consolidation. Smaller practices are closing, physicians continue to move out of state, and those who remain tend to look for jobs in larger practices or institutions. New graduates rarely consider entering private practice, instead favoring job security and lifestyle.

How can our physicians weather these turbulent times and continue to find gratification in the practice of medicine?

Team up. Especially for primary care providers, the environment is no longer so conducive to the single-physician practice. Group practices enable sharing of administrative burdens and can offer the ability to insource functions such as billing, payroll and IT, resulting in more practice control and better outcomes.

Build a supportive, efficient and nourishing work environment consistent with the adage, “Physician, heal thyself.” While there are many external factors beyond our control, physicians can still create their own oasis amid the tumult. There is much to be said for an intermediate-size practice where many of the burdens of a small practice are now shared but the multiple layers of administration in large organizations can be avoided. Manakai has seen a welcome increase in physician inquiries, which, happily, continue to expand the clinical team.

A few weeks ago I met with Dean Hedges of the University of Hawaii John A. Burns School of Medicine and discussed ongoing rotations for medical students at Manakai. Much of our meeting focused on the importance of team-based, collaborative care. I also just visited the University of Washington where I have been working with leadership in the Department of Family Medicine. The department leaders would like to establish a new rotation for its residents at our facility, again with a view toward imparting a culture of mutual support and synergy among providers.

Be pragmatic and pick your battles. We would all be burned out if we sought to fight every injustice. The key is to be discerning and to know when to let go, when to take a swing and which issues are worth taking to the mat.

The opportunity to practice the sacred art of medicine is still among the greatest privileges. The ability to sit with another human being to understand and treat what ails can still be as gratifying as it has been in years gone by. Faced with the decision to practice medicine today, I would do it all over again. No question.

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Future of US Healthcare Highly Uncertain

Future of US Healthcare Highly Uncertain

Wealth of Health, Money Section

Honolulu Star AdvertiserSaturday, October 6, 2018

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Future of US Healthcare Highly Uncertain

The road ahead for US healthcare remains highly uncertain. The Affordable Care Act (ACA), also known as Obamacare, quickly covered approximately half of those who were previously uninsured. However, while fine-tuning to deliver its central aims of access to quality care at  reasonable cost, all three branches of government have posed troublesome challenges. Multiple efforts to repeal and replace the ACA have failed, and instead, its foundation has been actively weakened. What next? While the majority of the public is opposed to a repeal of the ACA, intense uncertainty has spawned a range of competing initiatives for the future of US healthcare.

Medicare-for-all: Under this scheme, the US would move toward a government-run, national healthcare system more consistent with that of the majority of modern nations. Of note, during the recent democratic primary elections, the majority of the candidates who prevailed are moderate-leaning and their support of Medicare-for-all is far from assured.

The benefit of Medicare-for-all is that legal residents and citizens would all have access to care, something the ACA has not yet fully achieved. With greater government oversight, costs may also go down, possibly bringing the US more in line with all other national health systems which spend considerably less per capita.  The downside is that care would become more homogenized and access to expensive new and life-saving treatments is sure to be more limited. The transition to such a system would be tumultuous.

Repeal and Replace, or just continue to erode:  Multiple attempts by Congress during the past two years to quit the ACA have failed. It remains unclear what would replace it. While full repeal is now unlikely, continued efforts to erode the current system may continue. Examples include the elimination of the “healthcare mandate.” That is, the unworried well can opt out of insurance participation without tax effect. This increases premiums because those who do participate, represent a higher risk population. Medicaid block grants to states shifts costs and the burden of responsibility away from the federal government. “Skinny Plans”, one more blow to the ACA enables participants to reduce premiums by reducing the menu of coverage.

Improve the Affordable Care Act: In contrast, another real possibility is that the country will get back to the work of refining and improving the ACA in a manner that continues to increase access to quality care, and reduces cost while improving efficiency.  Efforts must be directed to stabilize insurance markets and bring premiums under control.

End-Around by Private Sector: Recently, JP Morgan, Berkshire Hathaway and Amazon announced that they would collaborate to build a separate healthcare system for their employees.  Remember however, that the responsibility of a publicly traded company is to its stockholders, not its patients. While a new private system might offer lower prescription drug costs, greater efficiencies and more technological solutions to access, diagnostics and treatment, would this work toward the best interests of those who are sick?  Increasingly, our personal data is hijacked as we access search engines, communicate via social networks, and buy online. If we are opposed to subterranean influences on our behavior when we purchase breakfast cereal or sportswear, we shouldn’t be surprised by who might now influence our healthcare decisions and to what end?

Hawaii Buffered: While Hawaii is not immune to any of the above initiatives, it is somewhat buffered. The Prepaid Healthcare Act ensures that employees who work 20hrs per week for 4 consecutive weeks are offered health insurance by their employer. Quest, a unique insurance product that combines Federal and State dollars, has for years optimized the number of covered lives in Hawaii. The late Senator Inouye ensured that Hawaii would not be made to accept any provisions of the ACA if they were less favorable than what already exists. Finally, the Hawaii State Legislature has signaled its determination to create a backstop to the prospect of a repeal of Obamacare.

Uncertainty about the future of American healthcare is uncomfortable for all including patients, providers, payers and governments. It is comparable to the downward pressure of uncertainty in the stock market. We live in interesting times.


Ira “Kawika” Zunin, MD, MPH, MBA, is a practicing physician. He is medical director of Manakai O Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. His column appears the first Saturday of every month. Please submit your questions to info@manakaiomalama.com or for more information go to: https://www.manakaiomalama.com/

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Integrity Diffusion

Integrity Diffusion

Ira Zunin, M.D., M.P.H., M.B.A
Medical director of Manakai O Malama

Today’s society has an abundance of quality professionals you can trust. They are well trained, highly experienced, caring and good at what they do, capable people upon whom you can rely … with one exception. Little gets done on time. Despite the best of intentions, execution is routinely delayed and, without repeated reminders, might never happen. This impairment in the conduct of business and personal relationships has reached epidemic proportions. I call it integrity diffusion. Tragically, it is the new normal.

In the era of online and mobile communications, we have the ability to maintain a plethora of personal and professional relationships — far more than ever before. So many that we fail to do them justice. Because the majority of these relationships are neither real time nor face to face, we often feel less obligated to honor our commitments and follow through on what we have agreed to.
In the old days a job application required a resume and a cover letter in a stamped envelope. Now, using Craigslist, with a few key strokes one can apply for countless jobs even if unqualified. “Yes, I’ll be there at 10 a.m. tomorrow to interview.” But then another call comes in, for a position slightly closer to home. “No problem, I’ll be there at 9:45 a.m.” Yet there is no sense of responsibility to cancel the first appointment. Result: another no-show.

A teacher of mine once said that every time we honor  commitment, it brings us power. When we fail to deliver, our human connections weaken, our personal credibility dissipates and we suffer from integrity diffusion. It not only erodes the local community. It also affects society in a pervasive manner, reducing productivity and efficiency.
It is the product of the GPS mind in which our focus jumps from one random input to another, stretching thin our relationship to self and ohana, leaving us with little sense of place.

No one is automatically immune to integrity diffusion. Not lawyers, accountants, builders, PV installers, politicians or health care facilities. “I’ll have it to you by the end of business today.” Yet in the interim a hundred other inputs touch us, and, unaware, we drift away from our commitment. It happens so often to each of us that we have come to consider it a nonissue. “Whatever, I’ll get to it in the morning.” But when we awake the next day, there is a whole new set of texts, missed calls, emails, Twitter, Facebook, Instagram, Viber, WeChat and other messages.

What to do? At Manakai o Malama we train staff to use a technique we call “Close the ticket.” When staff are asked by a patient, supervisor or colleague to complete a task, one first acknowledges the request, and a projected time to completion is agreed. This opens a ticket. The ticket is not closed until two things happen: First, the task must be completed; next, confirmation is sent to the one who made the request. If there is a delay or an unexpected challenge, possibly related to execution by a third party, that must be communicated. “I thought this would get done by lunch time, but I need another 24 hours.” The key is to remain accountable until completion and to communicate.

No one is perfect, but understanding that we live amid an epidemic of integrity diffusion is the first step toward healing this modern disease. Setting one’s intention to live a life of integrity and accountability is the next step. The third step involves maintaining awareness and focus. Step four involves active and responsible communication. Eventually, it becomes second nature. Actually, integrity is our true nature and key to being pono. Guard against integrity diffusion. Doing so will strengthen personal relationships, enhance business success and make the world a healthier place.

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