Something New

Welcome to Maven Clinic's new clinical newsletter, The Preprint. For this first issue, my perspective on where we go from here in digital health.

Last year, like so many others, I switched jobs.

As an academic physician, I never thought I would do anything else. I took care of people in my clinic and helped deliver their babies. I directed a research program and helped interpret the latest data on maternal health for the broader public. 

Until the pandemic took hold, I focused on improving our health care system as it is structured today. But COVID-19 disrupted everything about my job, the lives of the people I aimed to serve — and my worldview. I realized that health care needs to be reconstructed. And it needs different kinds of builders to do it.

The case for building differently

I practice medicine in Boston, a small city that boasts one of the highest physician to population ratios of any metropolitan area in the country. We have five major medical centers within a short distance of the city center. Our hospitals always seem to be erecting new towers. Yet significant numbers of Bostonians remain underserved, even for essential services like pregnancy and childbirth. 

In my city and every city not everyone has equal access to care. Their physical location — the neighborhood they live in — often determines their opportunities to thrive. In Boston, those who live in Dorchester fare worse than those on Beacon Hill. In New York, those who live in the West Bronx fare worse than those who live on the Upper East Side. Redlining and decades of structural divestment has made physical location inextricable from wellbeing. The pregnant people who need my help most are also the ones that need to take three buses to attend appointments at my clinic. 

This strong dependency of people’s health on where they live is unjust — and infuriating. On average, Black people living in the United States are three to four times more likely to die in childbirth than those who are white. But in particularly segregated cities like New York they are eight to twelve times more likely to die. For every death there are hundreds of mothers who suffer major complications and tens of thousands who suffer from undertreated illnesses and economic disempowerment during their family building journeys.

In March 2020, for pregnant people across the country, the challenge of accessing reliable health care and support became worse. In the wake of COVID-19, fertility services were completely suspended. Prenatal care, a fixture of most people’s pregnancy experience, transformed from 14 appointments over nine months to a mix of virtual visits and rare in-person encounters. After giving birth, social distancing made the already isolating experience of parenting an infant lonelier than ever.  

I could see from my practice and from my research that the brick and mortar health care system has been too constrained to meet patients’ needs. Even under normal conditions, when appointments are canceled in this system it can take weeks, even months, to reschedule. When people need care they also need physical transportation to access it — in many cases also taking leaves from work or childcare for large swaths of their day. If a lactation consultant, dietician or other particular form of expertise is not physically in-house, it is simply not made available. No amount of cranes in the sky or clinicians on the ground can fix these fundamental problems.

Healthcare comes online

All service industries were constrained by the limits of the physical world, from banking to grocery shopping to entertainment — until recently. The ubiquity of online support, home delivery and streaming transformed the ways we live our lives. By comparison, health care has been notoriously slow to enter the digital age and remains far behind (I still carry a pager and my hospital office still contains a frequently used fax machine). 

COVID-19 forced me and others to reimagine what could be possible if we deploy the same digital capabilities we take for granted in other aspects of lives in service of those who are vulnerable and in need of health care. It made me imagine a world in which prenatal services are not just based on a fixed and prescribed schedule, but also delivered based on a pregnant person’s needs and requests. It made me imagine people connecting with providers of their choice, in the language they speak, with a personal identity they shared — all from the convenience of a phone.

To be clear: babies cannot be delivered through a screen. Still, there are many moments when digital care can have a big impact on a person’s wellbeing. And this opportunity is growing: according to Cisco’s annual internet report, one year from now, in 2023, the number of internet-connected devices will outnumber humans 3 to 1. Venture capitalists have invested more than ever in digital health, surpassing 2020’s total in VC fundraising at last year’s halfway point. While many believe recent valuations and IPO performance among start-ups may represent an expanding and soon-to-burst bubble, I see real substance amid the noise.

A new kind of care — and what this newsletter is about

Here are three questions a provider might come across at various points in their career caring for new and expecting parents.

• How do we support a breastfeeding mother who is struggling to help her infant get a good latch — not between 9am and 5pm, but at 3am when she actually needs the support? 

• How do we meet people in the context of their lives, for example connecting someone with gestational diabetes to a dietician who can look at her fridge with her in real time and plan a low sugar meal? 

• How do we connect someone who is using substances to help — not only a methadone prescriber who may be far away, but the type of behavioral and mental health support they may need to get better? 

Before digital health, none of them would be readily solvable. Today, they’re all possible at Maven Clinic.

The question for digital health is not how this new kind of care can replace the physical — it’s how care can be reimagined when physical proximity to services is no longer a hard constraint, when large and expensive facilities are not required to support health.

I hope to document some of that work here. Every month, my goal will be to share what we are curious about at Maven by engaging with the work of others in and around our space. From time to time I’ll interview the most innovative people I know — physicians, scientists, activists, and even artists — who are helping to define new standards of care. I’ll also round up some good things to read.

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What my team is reading, considering, and building against

• The Times opened 2022 with an important story on the use of noninvasive prenatal testing (NIPT) to identify rare genetic conditions. NIPT is a breakthrough technology that is almost science fiction, using free-floating fetal DNA in the maternal bloodstream to detect chromosomal abnormalities. More than one third of pregnant women currently make use of NIPT. It has significantly improved our ability to identify conditions like Down syndrome and holds promise for other conditions as well. But right now, for less common conditions, the tests more often than not deliver false positives — for some conditions, 90% of positive diagnoses ultimately prove incorrect.
  
  There are a number of questions raised from this reporting, on how tests are approved and marketed, on how results are explained and contextualized. As a physician, what’s most important to me is the patient’s experience. Pregnant people are inundated with opinions at all points in their journey, from well-meaning friends and family, from the less well-meaning hive mind of the internet. It is very common to feel anxious and to worry over changes in the body, to compare oneself to gestational thresholds and start to think the absolute worst is about to happen. As we press forward with innovation and research to advance healthcare, we can’t forget who we’re supposed to be serving, and what it really means to make progress.

• This is an excellent piece in JAMA from Jessica Cohen and Jamie Daw on what they call ‘postpartum cliffs’ — moments in the maternal care journey where we fail to properly support new and expecting patients. The first two items in the chart below are especially familiar to me — and a big reason why I made the jump to Maven Clinic. The potential to provide something intuitive, simple, and accessible to patients at every stage in their journey — from pre-contemplation to parenthood — opens up all sorts of opportunities for improving their care. And I’ve long felt that pregnancy is under-appreciated for its central role in the healthcare system. Often it is the first time our patients interact with healthcare in any meaningful way, and our ability as OB-GYNs to uncover illness and direct our patients to the appropriate experts is a largely untapped but hugely valuable area within healthcare. We’re going there at Maven.

  

• One of the things that surprised me when I first started out in medicine was how little doctors knew about the cost of care. Healthcare makes up 20% of US GDP, which is a number we hear about a lot, but the way that shows up for individual patients is something of a black box — and a big reason why I started Costs of Care earlier in my career. This story from KHN highlights how much can still go wrong when a patient does everything right. Bisi Bennett’s journey through the gaps of our billing system — while recovering from a breech birth and navigating the anxiety of her newborn’s long NICU stay — is yet another entry in the ignominious canon.

• Fibroids are usually noncancerous tumors that grow in the muscles of the uterine wall. They’re common — with some estimating up to 70 percent of women will develop them during their reproductive years — but, for reasons still not well understood, they’re much more common in Black women. I appreciated this piece both for its accessible language and for the honesty of those interviewed.

• Finally, I’ll close on a topic near and dear and one I’ll return to frequently: the wellbeing of our healthcare workforce. COVID-19 has exacerbated provider burnout and compelled many healthcare workers to leave the field entirely. Burnout is not caused by hard work. It is caused by moral injury. It is caused by a misalignment between the purpose of working in healthcare and the process of delivering health care. For any new model of care to succeed we must consider how to improve the experience of providers and to do so by realigning purpose and process. For those readers who are themselves in clinic right now, I found this piece, in which comic artist and hospitalist (and friend and medical school classmate!) Dr. Grace Farris highlights the creative pursuits of colleagues across the country, to be just the sort of inspiration I needed to begin the year.

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Thank you for reading this edition of The Preprint. Have thoughts or feedback? We’d love to hear from you — reach out at thepreprint@mavenclinic.com. And if you'd like to be a part of our work here at Maven Clinic, check out our open roles (including several on our clinical team) here. You can also follow me on Twitter @neel_shah.