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Showing posts from 2009

questioning everything: CT scans and cancer, coffee and diabetes

Computerized tomography, otherwise known as CT or Cat scanning, has imaged 70% of non-elderly adults in the last 3 years. The use of this technology has been steadily rising, and we now perform a total of over 19,500 CT scans per day in the US.CT scans use a computer to organize x-ray data in such a way as to produce pictures that resemble cross sections of the human body, complete with bones, brains and soft tissues, tumors and blood vessels. The pictures are truly marvelous and have revolutionized the way we diagnose disease, allowing us to know many things about the insides of a person without actually cutting them open. We can see if a tumor is present, has spread, if an aneurysm is bursting or if the excruciating pain in a person's belly and back is a kidney stone or pancreatitis. We can tell if a victim of trauma is bleeding internally or if a mysterious fever is caused by a well hidden abscess.In December's issue of the Archives of Internal Medicine, researchers from th…

mammogram screening, take 2

I finally read through the 3 articles in the Annals of Internal Medicine that addressed the new recommendations from the US Preventive Services Task Force (USPSTF) about the recommendations for mammogram screening and breast exams. These have led to angry reactions, mostly based on lack of information and lack of understanding of the science behind the recommendations.First of all, the USPSTF is far from the only organization to weigh in on screening recommendations. There are organizations such as the American Cancer Society, the American College of Obstetrics and Gynecology and various other official groups from various branches of medicine. The USPSTF is, however, the most evidence based of the groups, the least financially motivated, and the most conservative.The recommendations of the USPSTF are categorized according to how sure they are that they are right, and changes come after long discussion and detailed evaluation of the research and the opinions of other organizations. I…

missing the safety net

What if you graduated from high school, left home, got a job delivering pizza, and were critically injured in a motor vehicle accident?

What if you had a part time job at a big company, a house, a family and got cancer?

What if you lost your job and your 8 year old daughter got appendicitis?

In the United States there are systems that act as safety nets for situations such as these, but they are not self sufficient and are severely strained in their ability to provide services with the progressive loss in adequate insurance coverage, the floundering economy and the increasingly outrageous costs of various forms of medical care.

If you were the first guy, ejected from your Geo Metro when you were t-boned at an intersection by a drunk driver, you would be taken to an emergency room at any hospital, transported to a trauma center if necessary, and treated until you were on the mend by that hospital. If you were eligible for medicaid or medicare due to the severity of your disability the hosp…

How the conference on affordable health care went

There were nearly 30 people there, at a not much more than 40 bed hospital. This is unprecedented for a not-required noon meeting. There was food, but it wasn’t very good, so they were there for the content (or maybe they though the food would be better.)The radiologist talked about appropriate use of technology and reducing unnecessary testing. Primary care docs talked about ways to make the computerized medical record systems give information about costs. The pharmacist talked about how to find out good information about drug costs, and we discussed ways to educate docs in the hospital on alternatives to the most expensive medications. We discussed other methods for reducing pharmacy costs which will also have other health benefits (changing medications given by vein to ones given by mouth, for instance.) The hospital CEO was willing to commit to putting into practice a system that would promote cost transparency for providers and patients. We talked about shifting responsibilities…

Framing a conference on making health care affordable

Tomorrow will be my first attempt at bringing the health care providers from my community together to discuss how we can change our practices to make health care more affordable.I approach it with some level of trepidation due to the fact that doctors can be pretty defensive about change. Nevertheless in many one on one conversations I’ve noticed that all of us are to some extent disgusted by how much health care costs, and by the fact that this means that many people don’t have access to good care.So what will I say to a group of internists, nurses, family practitioners, radiologists, orthpedists and surgeons (if they show up)?I hope that it won’t be me talking at them, since I already know what I think. But I will have to get the whole thing rolling.I am co-facilitating this with a radiologist who is motivated to change our doctors’ ordering habits for radiological procedures so they are at least ordering the right tests and not repeating tests unnecessarily.I intend to say:I’ve t…

We the people who love food too much

We the people who love food too muchNovember 23, 2009 by janiceboughton Every year we tell the story of pilgrims, coming to a new land to seek religious freedom, nearly wiped out by hunger and disease, and saved due to their resolve and some good advice by native Americans. I will not speculate on how much of that is true, but it is our story. We then tell the story of a meal shared to celebrate and express gratitude for their survival.The original Thanksgiving feast was probably not much of a spread. We have gone far in the last 200+years to make amends for that. I personally never remember a Thanksgiving celebration when it was possible to fit all of the food I wanted on one plate.Corn was one of the reasons that our predecessors survived. It grew easily, was forgiving of nasty weather and inadequate soil, and now is our major cash crop. We produce huge amounts of it, and so we make all kinds of stuff out of it, and instead of scrawny pilgrims, we are now round, well fed, and increas…

Pap smears and mammograms: what's the story?

If you've been watching the news, you may have seen some historic changes in recommendations about cancer prevention. There have been news releases regarding a change in the recommendations for mammogram screening by the US Preventive Services Task Force (USPSTF). Women in the 40-50 year old age group are now only encouraged to have regular mammograms if they are at increased risk of breast cancer, due to the fact that this test often finds non-existent of unimportant abnormalities in this age group that, on the whole, makes them less, not more, healthy. This will save women thousands of dollars and countless hours of time and energy at a time in their lives when that time and energy is a real gift.

Today I read that the American College of Obstetrics and Gynecology now recommends starting pap smear screening at 21 for most people, and reducing the frequency in that first decade to every 2 years. I have studied evidence based recommendations for pap smears for years, and the formu…

cool things we should all want (not)

Three articles in the most recent New England Journal of Medicine describe more new medical technology, and have made me curl my toes in mental conflict.1. A pacemaker that goes into both the right and left chambers of the heart, rather than just the right side, preserves heart function better, according to ultrasound tests. It is a much trickier (read inaccessible, expensive, desirable) procedure than the standard one, and the patients don’t actually feel any better or act any healthier than with the standard kind of pacemaker.2. Giving an intravenous iron supplement that I’ve never heard of before (new) (they didn’t test the ones I have heard of before) can improve heart function and health in patients who have congestive heart failure and are iron deficient. How odd that they didn’t evaluate oral iron supplements which have been generic since before I was born and are the standard treatment for iron deficiency. Is it just possible that the new product will be the only product appr…

Sermon to Unitarians on health care reform: Healing America's health care system

(this is really long compared to my usual stuff, but some people may want to read it anyway. It is a compressed synopsis of my many mini-essays that I delivered today at church.)

I love my job. It is possibly the best job that anyone could ever have. I get the chance to meet people of incredible diversity, and participate in decisions that they make about some of the most important aspects of their lives. I hear amazing stories. I get to solve mysteries, or at least try to solve mysteries. I get to interact with other doctors, who are some of the most interesting and committed people I know.

In the years I have practiced medicine I have been impressed often with the compassionate and effective care we can give to people regardless of their ability to pay for it, regardless of their social status, race or nationality.

So when I say that the American health care system is broken, I say it with love, and with the frustration that comes of knowing how good it can be.

The major problem that I…

unthinkable thoughts about preventive medicine

Of course it’s true that preventing disease is less painful and less costly than treating disease. Or is it?Take the recent New York Times article ( addressing mammogram and prostate cancer screening. Apparently over the last 20+ years of screening with mammograms, we have been able to discover many more breast cancers that are small, and might never have been noticed, and probably never would have progressed to the point of hurting anybody. This has given rise to alarming statistics, such as the one that breast cancer incidence has risen 40%.We have long known that detecting prostate cancer early, especially in older men, finds many cancers that would never have caused any injury and would never have been noticed had we not screened the men. When we find cancer, we usually remove it, and for women with breast cancer this means amputation of a breast or radiation therapy, and often chemotherapy. For men with prostate cancer th…

relieving suffering and reducing risks

Do patients actually know what they are getting from their doctors, and do they want it?

As I understand it, most patients want from their doctors primarily relief from suffering. And if they can't get relief from suffering, they would like to be heard and they would like to come closer to understanding the cause of their suffering.

When we prescribe cream for a rash, antibiotics for pneumonia or set a broken bone we are really right on the money. When we counsel and comfort we are doing the job we were hired for. When we get into the business of prevention, we are on a bit more shaky ground.

Much of our energy is spent haranguing, wheedling, threatening and assigning tasks. This is all in the service of preventing suffering, which isn't a bad goal when you think about it. We nag patients to take cholesterol pills, we assign them to go to obscure destinations to see specialists, we convince them to have painful and undignified tests like colonoscopies and mammograms. Many patie…

dialysis in the very old

As people age, their kidney function gradually goes down, usually keeping pace with overall needs. In people with longstanding diabetes or high blood pressure, though, sometimes the kidneys fail before the rest of the body does. In this situation, various toxins build up in the blood and such a person gradually becomes weaker and eventually dies.Enter kidney dialysis.With a machine that runs the blood through a filter, much as the kidney is a filter, the toxins can be removed from the blood. Unfortunately all of the blood needs to be run through that filter, which is somewhat tricky, and it takes about 4 hours, and needs to be done about 3 times a week.This is barely tolerable, but better than dying, usually, if you are pretty young, or only have to do it for awhile, as you wait to receive a kidney transplant.If you are very old, though, dialysis is physically stressful. The heart has to tolerate the movement of blood out of and back into the body, and all of the organs have to tole…

unthinkable thoughts, hypothetically

Last night I participated as a member of a panel speaking to medical students about issues relating to health care reform. Next to me was a respectable Blue Cross executive from the state capital, next to him a health care economist from the university and then two of my doctor colleagues. Our first starter upper question from the gathered masses was what we thought was the major problem with health care in America. The insurance guy and the economist said that people don’t take good care of themselves and so are in lousy health, and that they ought to take more personal responsibility for being healthier. This is what I keep hearing from Washington DC folks not in medicine, and although it is a truism, is it actually true?

Clearly, from the standpoint of bang for the buck, health and happiness and overall simplicity of delivery, the prevention of illness by avoiding overeating, drinking, smoking and drug addiction is powerfully attractive. Add to that physical activity with all of the…

Hawaii and the free market

Hooray for Hawaii! Apparently they have managed to get employers to cover just about everyone with adequate health insurance and their health insurance costs and other markers of health care efficiency are marvelous. Could it be the sea air? I am brought back to the dilemma that keeps popping up in the health care debate. Can we submit the business of caring for peoples’ health and diseases to market forces and bring down costs? As long as health insurance continues to protect people from exposure to the real costs of things, I don’t see market forces adequately coming into play. Only if health insurance companies actually acted like consumers would that really happen.Why are medications so incredibly and jaw droppingly expensive? Especially ones for diseases like cancer and transplants and severe diseases? Because people who have those conditions are ALWAYS insured, or else they die, and are not part of the equation…

Senate finance bill 10/13/09

A bill has passed the senate finance committee, with "bipartisan support", which means one Republican voted for it. The bill is only a tiny part of a health care reform package that will eventually by voted on in the house and the senate.

This tiny piece provides for more affordable universal health insurance, which is good, and will make those of us who have to negotiate for health insurance breathe a little easier. It would put an end to really heinous insurance company antics, such as canceling policies because people are sick. It allows for competition across state lines, stand alone dental insurance, expansion of medicaid and funding help for consumer driven health insurance options.

So it is good. It is not exactly what we need, but it does address some of the issues.

What we really need is still a radical reduction in costs. Although, as a health care consumer, I welcome anything that will bring some relief to those of us who suffer through having to pay for health ins…

Health Care--a right or a privelege?

Does every American citizen have a right to health care? How about "affordable health care?"

It's tricky, this question of rights. I would like everyone to have enough food, but everyone doesn't have a right to enough food. Or enough sleep. Or love...

Soon after 9/11, Mayor Giuliani of New York City said that every American has a right to freedom from fear. No, I think, they do not.

Traditionally, as a country, we have made laws that prohibit the government taking away our individual self determination, and placing strict controls on the ways in which our self determination can be restricted in cases of law breaking or conflict. We have also developed institutions by which we care for each others' needs, guarding against letting those who are vulnerable die of poverty.

As a health care provider, I balk at the idea that every citizen has a right to what I produce. It's kind of like telling a dairy owner that everyone has a right to cheese. Nevertheless, as a no…

Where does the money come from and where does it go?

All water is recycled. The drip from my nose was, at one point, the drip from someone else's nose and so on. And the same goes for money. There is a limited amount of money, as it represents resources, but it doesn't just go away when we spend it. So, with health care dollars, the problem with the 2.3 trillion dollars going to pay for health care isn't exactly that 2.3 trillion dollars, it is where it comes from and where it goes.An example in point: A friend of mine was just diagnosed with a particularly nasty form of brain cancer, glioblastoma multiforme. It is the most common malignant brain tumor, and it just killed Ted Kennedy. I don't have any idea how it chooses its victims, but it seems clear they have no fault in the process. He has already had 2 MRI scans, brain surgery and 5 days of hospitalization around the brain surgery. He also had an ambulance ride and several doctors' visits. He hasn't got the bill yet, but my guess is that he has just…

Excuse me Mr. Obama--here's the money you were looking for...

Now, like the beginning of a mudslide, there are people, doctor people, writing about why it costs so all fired much to deliver medical care in these United States. There are articles in the New England Journal of Medicine, that staid periodical with the plain white cover, and just this week an article in the Journal of the AMA which explains exactly how the costs of medicine can be curbed, resulting in better care.

The sound of this message is a murmur that is steadily increasing in volume. I'm not entirely sure that anyone in lawmaking positions is hearing it yet. Perhaps when it gets really roaring they will.

I was feeling frustrated by the apparent near inaudibility of this message until today at about 1:30 when, while walking on an old logging road, I realized that it doesn't really have to be heard by law makers. Now, if they did hear it, they could be substantially relieved to know that costs are going to go down, but they don't even have to know that. Perhaps it will…

Senator Baucus' proposal--are health care co ops a bad thing?

I just skimmed the 223 pages of the health care proposal by Senator Baucus, with a focus on the health care cooperative suggestion and the mention of medical malpractice reform.

There are lots of sections in this proposal, and most of them contain good ideas. Achieving all that is in it would be a humongous and monumental amount of work. It also nearly completely misses the boat in terms of cost savings.


The proposal suggests that we establish health care cooperatives as an alternative to presently available insurance plans, that work about like Group Health does now. Group Health is a cooperative based in the northwest which provides full health care services to members for what looks like a reasonable price compared to what most health insurance costs. It provides basic services easily, emergency services competently, and focuses on prevention. It provides good care for serious illnesses of all kinds, and skimps a bit on cutting edge technology and medications. Sometimes members…

What American health care system, exactly?

People throw around the expression "American health care system" like it was something that actually exists. Britain and Canada have health care systems, and in the US of A we have things like Kaiser and Group Health and the VA which are health care systems, but we don't have "A health care system". What we more accurately have is a bunch of professionals who provide services that are sometimes random and sometimes coordinated, having to do with caring for peoples' health and diseases.

Because we don't have a health care system, it is hard to fix it.

Most of our health care is delivered by people who see themselves as individuals delivering a service. In addition to delivering the service, these individuals want to make as much money as they can, consistent with keeping the client happy and healthy. This model does not lend itself well to cost efficiency.

Today our office was provided lunch by a well dressed representative of a medical equipment company. T…

What if I had 3 minutes to make my case

What if I had 3 minutes with a health care czar to ask for what I think we need

Okay, the timer is running...

1. Reduce costs of health care by a. reforming the malpractice system at a federal level to reduce malpractice insurance costs and reduce "cover-your-ass" medical spending b. introducing cost transparency, whereby providers and patients know what everything costs and can make informed decisions and c. creating teams of healthcare professionals to identify waste in practice and administration.

2. Insure everybody by expanding medicare to cover those who can't afford insurance, and revamping medicare to encourage a "medical home" model that provides care for patients through primary care providers who know them well. This would include better coverage and compensation for patients and providers who participated in the new medicare program, and education in cost effective and appropriate medicine to providers of care.

Bedtime story

Once upon a time there was a big country with not very many people living in it. They were farmers, and ranchers and teachers and people who sold things that other people needed. There were doctors, too, who gave advice to the sick, did minor surgery and comforted the dying. The doctors could set bones, bandage wounds and tell people approximately what was wrong with them, but they couldn't do much to fix people who were sick. Eventually the doctors made schools to teach each other what they knew, and educate new doctors who would know a bunch of things right off, rather than having to learn them as they went along. The new well educated doctors were respected because they were able to help people who really needed help, so smart young people wanted to be doctors. In the medical schools the teaching doctors were able to discover new ways to treat the dread diseases that they saw, and so the job of doctoring was associated with more respect. With the respect came good pay. When …

What's wrong with spending trillions of dollars on health care

A couple of years ago I decided that the reason that Americans spend so much money on health care is because it is our national pastime. In Brazil they like soccer and Carnival, and in France they like fine wine and good food. In the US, we like our MRI scans, our bypass operations, CAT scans and the whole gory and dramatic process of getting them and discussing them. When we have a spare moment, we talk about going to the doctor and what tests the doctor ordered and what the doctor said. We have other hobbies, true, but we are very interested in things medical.

When I developed this theory of health care as a national pastime, I saw it as interesting and neither particularly good nor bad. It seemed that any national pastime costs money, and the money that is spent on it goes to pay the salaries of the many people who provide the goods and services related to the pastime. Since medical care consumes such a large amount of money, it must support many households whose wage earners mak…

Computers and the medical record

Many of the elected officials who I respect--President Obama, our own Idaho congressman Walt Minnick, and anybody else appropriately fired up about health care reform--say that we will all be better off when the records of our blood tests, medical procedures and office visits are made accessible by computer. It sounds simple and beautiful. Two and a half years after starting to use such computerized medical record keeping system I have a few opinions about how good it is, and what it is really good for.

In a state of unrealistic optimism, many health care reform proponents are saying that electronic medical records will, when combined with Americans adopting healthier lifestyles, save enough money to pay for health care for the presently uninsured. Healthier lifestyles are indeed a money saver, but I'm not exactly sure what transformation is supposed to happen to make us eat less crap and stop smoking.

On the other hand, though, a computerized medical record is not a cost saving …

Do no harm

After finishing medical school, we all stood together in the big hall where we had been educated for 4 years, and took the hippocratic oath. The only part of the oath that I remember well is "primum, non nocere." Those words recognize that a doctor has the ability to harm as well as help, and needs to have the humility to recognize that.

Today in the New England Journal of Medicine, the most well regarded journal of research and practice for internists, an article appeared that referred to medical harm. I think it may be available to non subscribers at The author looks at the evidence of help and harm from radiological procedures that are done to prevent disease.

The number of CAT scans and heart imaging studies that are done is rapidly increasing, and yet there is no evidence these save lives or improve health in most instances. There are definitely times when they are helpful or appropriate, but most of them may be time an…

Why do doctors make so much money?

In the discussion of why American health care is so expensive, it is certainly necessary to entertain the question of why doctors salaries are as high as they are. The average American makes $38,000 a year, and the average primary care doctor makes around $150,000 a year. These numbers vary by geographical region, certainly, and the primary care doctors I talk to in my small Idaho town mostly make less than $100,000. But they certainly do command a higher salary than teachers or carpenters or most university professors at our esteemed and underpaid state university. So why is this?

To practice medicine, a doctor has to finish 4 years of university, 4 years of medical school and at least 3 years of residency as an MD in training. In order to get into medical school, they need to be in the top of their university classes, and have finished a set of premedical requirements that is heavy in science and math. Medical school is an order of magnitude harder than university. The first two year…

Cost shifting--is that why hospitals charge so much?

If health care costs go down significantly, as providers order less unnecessary tests, and as tests and procedures come down in price due to the incentives of actual competition (OK, I'm making a rather huge and optimistic assumption) hospitals will see less money coming into radiology departments and labs. When there are more primary care doctors available to see patients, and patients seek care earlier in the course of their illnesses, there will be less patients seen in emergency rooms, and hospitals will see that revenue go down.

Or will they?

If we truly get universal healthcare, the amount of uncompensated care that hospitals have to cover will be dramatically reduced or completely eliminated. Right now if an uninsured young man is brought into the emergency after a gunshot wound, that man will get top of the line trauma care, with specialists called in, multiple imaging procedures, needed surgery and medications, and the hospital will simply eat those costs. It is not clear t…

Cost transparency--what's not to like?

Cost transparency, that is making sure that patients and providers know what everything costs at a time that is relevant for discussing options, is a great idea. The effects of sharing this kind of knowledge would be powerful. Cost could become part of conversations about what is the most appropriate care. A patient could ask if a particular $3000 test would really change their treatment, for instance. If everyone knew, up front, what things were supposed to cost, billing errors and fraud would be much easier to identify. And when things cost way too much, we could start asking why, and begin the process of making these costs competitive.

There are, however, some pretty serious obstacles to making this information available.

I would like a patient to know, before she even sits down with me, how much her visit will cost. Unfortunately, I don't know. The amount of time and complexity of the encounter, including office procedures that might have to happen, will unfold during the vis…

Why isn't malpractice reform an issue for the democratic party?

Malpractice reform is not traditionally an issue that Democrats support. Why?

I think it is because democrats feel strongly that everyone, no matter how poor or disenfranchised, has a right to his or her day in court.

This is good: we are right to hold on to systems that allow people who have been wronged to be heard. But our tort system does not work in the case of medical injury and malpractice.

Most people with a medical injury never sue for malpractice. Most of their injuries are too small for a lawyer to take the case, and many of the injured don't want to enter into the complex and contentious world of the legal system.

Most cases that go to court are ones in which a person has a very bad and often expensive outcome, in which a lawyer could hope to get an amount of money worth his or her time. Most of these cases have no convincing level of negligence, and so there is no significant benefit for the injured party.

During the time that the case is being prepared, usually a number …

How to fix it

The problem:
Health care costs too much, insurance costs too much, and people are suffering because of money spent directly in bills or indirectly through taxes. Because of the cost of insurance and health care, too few people have access to it.
Scope of the problem:
Huge. Because of the lack of access, America’s indicators of overall health, including infant mortality and average age at death aren’t as good as most countries we consider our peers. Because of the cost, average Americans’ take-home salaries are significantly lower than they would be and federal and state governments are unable to afford other basic services such as education and other social services.
Causes of the problem:
1. Doctors practice medicine that is not cost effective because of worry about malpractice, and perceived patient expectation that costs are not a consideration where health is concerned.
2. The number of primary care physicians is shrinking because primary care physicians are not paid as well as medical…