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Join neurosurgeon Katrina Firlik as she delves into the world of health care data and the importance of citing sources. Explore her journey from treating patients to becoming an entrepreneur, and learn about the challenges of addressing medication nonadherence. Discover the impact of industry standards, peer pressure, and the quest for reliable facts in the medical field.

Katrina Firlik is a neurosurgeon.

She discusses the KevinMD article, “The unstoppable momentum of a medical ‘fact’ with no source.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Katrina Firlik. She’s a neurosurgeon, and today’s KevinMD article is titled “The unstoppable momentum of a medical ‘fact’ with no source.” Katrina, welcome to the show.

Katrina Firlik: Thanks for having me, Kevin.

Kevin Pho: So let’s start by sharing your story and journey to where you are today.

Katrina Firlik: I started my career as a practicing neurosurgeon out in Connecticut, and did that for a number of years, and then kind of got bit by the entrepreneurial bug, so to speak, and was inspired to start my own company. And I picked a topic that was near and dear to my heart, which was medication nonadherence.

Because I was always kind of positioned at the end of the line as a neurosurgeon, treating patients with, for example, bleeding in the brain after poorly controlled high blood pressure, and realized that the problem of nonadherence was such a major contributor to complications from chronic disease, but there was almost no innovation being brought to bear to the problem. And so I saw all these innovative solutions in surgery and devices, and I saw no innovation in that field. So that’s what led to me co-founding my company that I’m now chief medical officer of. It’s called HealthPrize Technologies.

Kevin Pho: So you were a neurosurgeon, which is one of the most demanding medical and surgical subspecialties. So tell us about that journey from being a neurosurgeon to your entrepreneurial ventures.

Katrina Firlik: Yeah, it’s a very circuitous story. And I absolutely loved neurosurgery, that was really kind of my true passion, and loved taking care of patients. And then as I started getting into the startup idea and started going deeper and deeper, I realized that it was very exciting for me to be on that steep part of the learning curve, in terms of building a company, trying to solve a really huge unmet need that I thought really was not being adequately addressed.

And at first I thought, maybe I can juggle both and do neurosurgery and start this company, but it turns out that was pretty difficult. So I did make a very difficult decision to at one point go part-time with neurosurgery, which is not really sustainable, I mean, who wants a part-time brain surgeon? And then went full-time into the startup world. So it was not an easy decision, and I definitely have some regrets making the decision, but in the end I think it was the right path for me.

Kevin Pho: So as you were a neurosurgeon, you saw the problems of nonadherence and noncompliance. So give us some specific examples during your neurosurgical career of how that adversely affected patients.

Katrina Firlik: Yeah, I mean, there were many. For example, maybe 1 percent of the population has an aneurysm and they have no idea, right? But what are the chances it’s going to actually rupture? Things like hypertension, diabetes, high cholesterol, things that lead to atherosclerosis and blood flow issues, can cause it to rupture.

Bleeding in the brain from poorly controlled hypertension can cause obviously hypertension related bleeds in the brain. Frequently patients with poorly controlled diabetes we would do, for example, a spine fusion on, and there were wound healing issues, complications related to infection that were clearly contributed to by the poorly controlled diabetes.

So there are multiple examples of this, and obviously every doctor sees this in their practice. But for me it was kind of an eye opener when I dug deep into the problem, realized just how huge a problem it was, and then realized how little was actually being brought to bear to try to help solve it.

Kevin Pho: So we’re going to talk more about that in your KevinMD article titled “The unstoppable momentum of a medical ‘fact’ with no source.” So tell us how your article came together.

Katrina Firlik: Sure. Well first, just a brief background of the company, which then leads into the article. We realized that medication nonadherence is not just a problem of cost. Obviously cost is an issue, but it’s a problem worldwide, even for patients who pay no out-of-pocket cost. Forgetfulness is an issue too, but it doesn’t really lead to the sort of nonadherence I’m talking about. If you skip a dose or two once or twice a month, that’s not really the brunt of the problem.

So we realized it was more of a problem of human psychology. So we created a solution looking through the lens of human behavior, human psychology, and it combines gamification, education, incentives, all in this kind of very consumer friendly and really enjoyable digital solution.

So when we were founding the company and we were raising money, and obviously the whole goal is to educate people about the problem, I was tasked as the chief medical officer with really kind of understanding the problem, communicating the problem, and helping potential investors and customers understand the problem.

So to that end I went on this massive fact finding mission. What are the data around medication nonadherence? And one piece that kept coming up over and over and over again in white papers and the popular press was 125,000 deaths per year. I said, OK, that’s a big one, I’ve got to stick that in every slide that I use.

But of course, in my neurosurgery career I wrote many papers and I was very well trained to always chase down the primary source. And I thought, I’m going to do that, I’m going to be rigorous. Even if I take on more of a marketing role in the company, I’ve got to be rigorous about the data, that is my DNA as a doctor.

So I found a source for the 125,000 deaths, and I’m like, OK, that’s a secondary source, they’re quoting something else. I chased that down, I kept chasing down sources, and it finally came to a CDC article, was the earliest one I could find. And I’m like, wow, I can finally find the primary source, after probably a dozen different tries. And it turns out it said nothing about death due to medication nonadherence. Because obviously you and I know that’s not a valid cause of death on a death certificate, which we fill out all the time. So how do you actually know a death was due to that?

So it kind of was an eye opener. I’m like, wait a minute, this is a great fact, I think actually more deaths are related to this, but the fact, I could not pin down a primary source, and I believe one doesn’t exist.

Kevin Pho: Yeah, because there are just so many secondary effects from people not taking medications, and how do you keep track of that? So what eventually happened next? How were you able to articulate that impact of medication nonadherence to your potential investors?

Katrina Firlik: Well, there are countless papers with really good primary sources that are relating degree of adherence to degree of clinical outcome, or even medical cost for example. So there’s reams of papers out there, many of which are very well done, showing for example, if you take your statin, you take your high blood pressure pill, or you take your diabetes medication, you have fewer outcomes and you end up costing less. So that correlation is very well understood and very well known in the literature.

And so there was no paucity of data, but that particular fact is still out there, and we ended up using it sometimes because everyone else was using it. So again it was also kind of this interesting psychology behind, well, everyone’s using it, our competitors in the field are using it, this is just the fact that’s out there now, and it’s stuck.

Kevin Pho: So because you were so rigorous, you realized that there wasn’t any primary source for that fact. So as you go through that whole health care entrepreneurial industry, how often do you come across these kinds of less rigorously sourced facts that are just spouted off by CEOs and startups?

Katrina Firlik: I would say, first of all, I believe in most cases it’s not intentionally done, so I’m not trying to say there’s some sort of scandal here. It’s more a laxness or laziness in chasing down a primary source, that’s actually the problem. So I don’t think people are intentionally trying to make up facts. There’s some similarity to politics, where you take facts or you cherry pick facts and they might not have the primary source. And once somebody with some influence quotes something, it just keeps snowballing. So I think that’s what happened with this particular one, there was not any sort of ill intent.

But I do frequently see secondary or tertiary sources being quoted all the time in medical papers. And I think that happens because, first of all, it would be an incredibly onerous task for the journal to go through and say, is this the primary source? Because chasing it down, you’ve got to go through paywalls, you’ve got to pay 30 bucks to look at the source, like, oh, actually that $30 paper I just bought isn’t the primary source, now I’ve got to pay another $30 for the next source. And it’s actually a very onerous and somewhat expensive task to chase down the primary source.

Kevin Pho: So getting back to nonadherence, you mentioned cost isn’t the only potential factor. What are some other main reasons why patients sometimes don’t go through a certain treatment or medication?

Katrina Firlik: Yeah, I’m glad you asked the question, because this is to me a fascinating problem. Again, it’s a problem of human psychology. Behavioral economics really gets into this too. If you look at why do people not save for retirement enough, it’s a similar psychology.

That for many medications the benefits are long-term, right? You’re prescribed a pill, they say maybe you take this and you can prevent a heart attack 10, 20 years down the line. The psychology is hard for you to take it today. It takes a trip to the pharmacy, you’ve got to pay the co-pay, you may have a transient effect for a few weeks that’s annoying, a side effect. So all these short-term downsides make it hard to take the pill for a very long-term upside. It’s just a fundamental problem called present bias, we’re kind of biased towards focusing on present benefit rather than future benefit. So that’s kind of an underlying psychology.

And then there are some people who, you probably heard this yourself, I’m not a pill person. And I’m not saying you need to take a pill for everything, and sometimes people are on too many pills, or a pill that’s not appropriate, certainly. But if it’s an appropriate pill for the appropriate disease, if you say you’re not a pill person, then I think you’re focusing too much on the risk of the drug and not enough on the risk of the condition. So it’s that risk benefit tolerance that I think people frequently don’t understand or aren’t perfectly educated about. So those are one of many problems, but human psychology plays a larger role than people actually think.

Kevin Pho: Now, in your article you also mentioned this may be a global problem as well, and not just confined to the United States.

Katrina Firlik: Absolutely, absolutely. And that’s what I bring up frequently when people say it’s all about cost. And again, cost is definitely an issue.

There was a great paper published in the New England Journal of Medicine where they took patients who had a heart attack, and half the patients they said, all your drugs are free, whether it’s for high blood pressure, cholesterol, anything, free, no copays. The other half, you’re on your own for copays. So you would think, oh my gosh, that’s got to have a major impact on adherence. It improved adherence by about five or six percentage points. It made a dent, and it was statistically significant, but I would say probably not clinically significant.

And so certainly an intervention of free medication does help a little bit, but it’s in the single digit amount. And we’re able to show adherence rates of 40 percent better if we do a carefully controlled population. So I think, and again, looking at other countries, even in places with costs covered to a much larger degree, like for example England, they still have an adherence problem very similar to ours. So again, cost is an issue, but it’s not as big as people actually think it is.

Kevin Pho: So startup companies like the one that you mentioned that you work for, there’s some technological solutions to this, and you mentioned things like gamification. So tell us the effectiveness of this approach to getting people to take their medications.

Katrina Firlik: Yeah. Well, the first hurdle is getting people to actually use a solution, right? There are a lot of well-meaning attempts to create digital solutions and then nobody really signs up for them.

So we realized that we need to kind of combine intrinsic motivation with extrinsic motivation. So let’s say you’re someone who’s not interested in taking your medication, maybe you don’t fully understand it, maybe you’re having a minor annoying side effect, you don’t like paying 30 bucks when you go to the pharmacy. Why are you going to sign up for a solution?

Well, we use the extrinsic motivation of, hey, sign up, you get a certain number of points, it’s very consumer friendly, it’s fun, the education is fun. And so at first you might be drawn to say, yes, I’ll sign up for this, because maybe you can get a $10 Amazon card at some point, earn points. Is that superficial? Yes, very superficial. But if it gets you to join, and then you get more points by learning about your hypertension, and then eventually some number of months later you’re like, oh, now I really understand, I fully kind of internalize why I need to take the medication, then it was worth using that extrinsic hook in the beginning to get someone to engage.

So we use this combination of the extrinsic, the intrinsic motivation, and then the gamification makes it actually fun, so people are incentivized to actually come in and check their leaderboard status, and there are streaks for example. So all these sorts of things that we know work in the consumer world also work in health care.

Kevin Pho: So tell us a success story where, in an ideal world, your solution really moved the needle for a particular patient.

Katrina Firlik: We have a lot of individual success stories. We have great feedback from patients saying, at first I just did this because it was fun, and then I realized, oh my gosh, now this is why I need to take my pill. Which is really what we’re getting at here.

But we have some great data that we’re getting ready to publish that I’ve already spoken about in a national meeting regarding COPD patients. And COPD is particularly difficult to move the needle on for a number of reasons, but we were able to show about a 40 percent improvement compared to careful controls, people that were in the HealthPrize program with their inhalers for COPD versus people not in the program.

And just to mention about this, these sorts of trials are actually very difficult to do. This was not a prospective trial but a retrospective, but carefully matching patients is extremely difficult, because who joins programs like this? It could be people that are already motivated. So we had to do what we could to match people carefully based on other healthy behaviors, to make sure we’re not just looking at the motivated patients in the program.

Kevin Pho: Now, do you see something like this being prescribed in primary care offices like myself? I would write someone for a blood pressure medication and, oh by the way, this is an app that helps remind you to take this medication.

Katrina Firlik: Yeah, we have used that approach. We have multiple different programs depending on the sponsor, and our sponsors are either health insurance companies or pharmaceutical companies. Depending on what medication you’re on, typically it is an email invitation, either through the medication manufacturer itself, like for example if you sign up for a co-pay card discount online you can also sign up for HealthPrize, or the insurance company. We’re running multiple pilots where they already know who you are, they know what medication you’re on, and they invite you to join. We would love to have it direct from doctor to patient, but that’s more of an implementation challenge.

Kevin Pho: We’re talking to Katrina Firlik. She’s a neurosurgeon, and today’s KevinMD article is titled “The unstoppable momentum of a medical ‘fact’ with no source.” Katrina, let’s end off with some of your take-home messages that you want to leave with the KevinMD audience.

Katrina Firlik: A bunch. One is obviously on the medication front. Think about the psychological reasons behind it. If you have a patient that you think is not a pill person, try to really get to the heart of what they’re nervous about. Are they nervous about a side effect? Do they just not trust the health care system? Do they have some confusion about why they need the medication? It’s really worth spending the time to get to the root source of the problem.

And then also kind of on the more personal front, burnout’s a big deal in health care right now, and I’d say in terms of my own personal story, think about what your practice isn’t necessarily helping you with in terms of expressing all parts of your personality. In my case, I wanted to do something creative. I also write on the side, so I’m a writer, and that allows me to express my creativity. The entrepreneurial side expressed a different part of myself as well. And so I think trying to realize all the different aspects of your personality and how to address them, whether it’s through the career or through a side hustle or through a hobby, is really important.

Kevin Pho: Katrina, thank you so much for sharing your story, time, and insight, and thanks for coming on the show.

Katrina Firlik: Thank you so much, Kevin. I enjoyed it.