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Tuesday, June 29, 2010

Community organizing for health care reform: what we have to do now

We had our 4th meeting of doctors and staff interested in improving access, cost and overall quality at our hospital. It was well attended, but mostly by staff and board members rather than physicians. I guess we doctors think we are too busy to talk about health care reform. We had me, an internist, a psychiatrist, a radiologist and and emergency doc. Thinking was clear and focused, and the meeting was productive, as much as talking can be. We came up with several items needing action, and discussed several items that are moving solidly in the right direction.

1. My Own Home: an organization is being born which provides all sorts of resources to older folks wanting to stay in their own houses rather than moving to retirement homes.  It will be supported by grants and will require membership payments. It will probably really start functioning in the next year. It is moving in the direction of getting up and running as fast as is practical.

2. Direct or prepaid medicine: there is quite a bit of interest by the hospital leadership in looking at some sort of community based prepaid health care.  This would involve using the money that is already being spent on health care, by individuals and insurance companies, to provide comprehensive health care for the whole community.  There are models for this elsewhere. Grand Junction, Colorado, has a system that provides affordable health care for the whole community, and we are a good size and makeup for that sort of thing.

3. Physical therapy--appropriate utilization and rapid transition to exercise programs: This is already happening.  There is room at the hospital wellness center and costs are low, so many people who go to physical therapy multiple times because that is the only exercise they every get can be transitioned into something much cheaper and more appropriate.

4. Information systems: The hospital just made the decision to buy an electronic medical record system, and will start using it, ever so gradually, in the next few months.  This will make monitoring of costs and outcomes much simpler.

5. Radiological testing--making it more appropriate to avoid excess radiation exposure and monetary costs: This will be aided a great deal by the computer ordering of tests. Criteria for appropriateness can be evaluated at the time the test is ordered, and duplication can be avoided.

6. ER use: There is still a great deal of money spent due to patients being seen in the emergency department when seeing a primary care doctor would be more appropriate. This involves excessive testing and insufficient followup, and is associated with higher costs than appropriate care would have generated. This will require a work group to figure out the best approaches. Some suggestions included diverting patients to primary care providers who indicate in some way that they are available and willing to work with these patients for a reasonable fee. Another helpful service would be 24 hour van transportation to get patients home after treatment and evaluation are completed. This kind of service would more than pay for itself, and the hospital CEO said he would move on that.

7. Cost-of-care clinical conferences: I would really like to present case conferences which look at the costs incurred at all stages of a patients hospital stay, along with the clinical outcomes. This can probably be done, with attention to confidentiality, and would really inform some of our choices. I will work on this.

8. Cost transparency for patients: the billing department is working on this, but the progress is slow.  They really need more staff to get an efficient interface working.

The hospital has been very receptive to ideas that involve streamlining care and costs, which initially surprised me. They are aware of a new climate of belt tightening, though, and would like to be involved in the process as much as possible.

Wednesday, June 23, 2010

CT scans--why not?

The New England Journal of Medicine this week published two articles on imaging technology.  The first was about the safety of CT scans and the second was about the indiscriminate use of radiological imaging of all kinds. Imaging of the human body is big business and important in the progress of diagnosis, but once a machine or technique is invented, its use is mostly unregulated and largely up to our discretion, without supporting scientific evidence of usefulness.

CT scans do cause cancer. This is because ionizing radiation causes cancer and CT scans carry lots of that. Every year 10% of Americans get a CT scan, and many people have multiples. Each CT scan carries 100 to 500 times the radiation dose of a standard chest x-ray if done properly.  If an error is made, much more radiation can be delivered. Sometimes a patient might find out about such an error, but most often there would be no symptoms and no recognition.

CT scans also do save lives.  They detect problems that would require emergency surgery before they are life threatening. They detect conditions which would remain painful or disabling mysteries for years without imaging. The trick is using them appropriately.

CT scans of the abdomen and pelvis usually carry the greatest radiation dosage because there is so much tissue that has to be penetrated in order to get a good picture. In this New England Journal article (http://content.nejm.org/cgi/content/full/NEJMp1002530?query=TOC) the patient in question got 2 CT scans of the head in short succession, arguably for no good reason, and one of them carried an erroneously high dose of radiation, resulting in significant brain toxicity. It could have happened to anyone.

Also an issue for this patient was the fact that a special CT scan called a perfusion scan was done to see if she was having a stroke. I have not ordered these yet myself, and just recently heard about a patient for whom such a scan was suggested as a way to evaluate an odd and transient symptom.  These brain perfusion CTs carry a much higher radiation dose than a standard head CT, with the risk of radiation damage to brain and scalp and obvious increased risk of malignancy. Since most of us have, at one time or another, had disturbing neurological symptoms, wooziness, confusion, dizziness and the like, such a scan may gain significant popularity in the future, with results that will be irreversible to the patients who receive them for inadequate indications.

Saturday, June 19, 2010

The pseudoscience of medicine

The training that leads to becoming a physician is long, taxing and requires academic stamina and intelligence to complete. Nevertheless, most of what we eventually learn is practical: how to take care of patients in sickness and health. This is as it should be, since that is what we mostly do. Nevertheless, because we take many many hours of science related classes, most physicians consider themselves to be scientists. And that we, mostly, are not.

In my years of training I have learned how to construct a hypothesis, test it and use my data to make a conclusion. I know how to document my data, and I know how to perform simple statistical analyses.  I know how to interpret statistics I read in other peoples' work, for the most part. But because I am always looking for ways to use the science I read to help me in patient care, I often make inferences that are speculative and probably just plain wrong.  It works for me, though. I need to plug the science I read into the craft of medicine I practice in order for it to be meaningful to me, and sometimes my inferences might just be correct.

Take for instance standard clinical trials which look at the effect that a certain intervention, say a drug treatment for cancer, has on a group of people.  That clinical trial will show that the in the group getting the drug the cancer will go away for a certain percentage of the people getting it. This result will be compared to results for a placebo group or a group getting a different drug. If the group getting the drug has a higher level of response than the placebo or different drug group, the interpretation will be that the new drug works. This is where the speculation starts to be misleading. I will then tell the patient I see that this new drug works best, and the patient may then choose to take it rather that watching and waiting or taking the other drug.  But it isn't necessarily true for this patient that the drug works best, because patients are different, and withing the group that got the new drug, there are very likely patients who would have done better getting no drug or another drug. So I really can't, and shouldn't tell the patient that the drug works better. But just to make it as simple as possible, I do. And most doctors, until they sit down and think about it believe that this is true, that the drug that comes out on top in the clinical trials is the best drug, and they will proceed to use it preferentially.

I have been attempting to explain this sort of thing to my patients more often since I have been thinking about it, but I think it just makes them uneasy.  They want an answer from me: what choice is best.  Now that is not true of all patients. Some of my more thoughtful patients are glad to have many options open to them. It is more honest to discuss these things, but they are complicated and definitely not reassuring.  The use of estrogen is a frequent subject for these discussions.  Estrogen causes various harms in some people, including increasing the risk of breast cancer and vascular events when combined with progesterone, but it also saves people from breaking their hips and reduces the risk of colon cancer. It definitely helps relieve the sleeplessness and hot flashes of menopause as well.  So is it good for a woman or bad for her? I guess it depends on what she values.

Another thing that physicians do that makes us feel like scientists is we measure things.  We measure how much pressure it takes to stop the blood flowing in someone's arm. We call that the blood pressure.  We measure the number of blood cells in a cubic centimeter of blood. We measure weight, temperature, height and head circumference.  We count the number of times we feel the blood pulsing in someone's wrist per minute. We are reassured of a person's health based on these numbers. The numbers themselves may be misleading, as in the case of the blood pressure. The pressure it takes to stop the blood flow in the arm can go up if the arteries are particularly tough and springy. We don't necessarily know that this is a bad thing. The blood pressure can vary depending on recent exercise, time of day and emotional state. But that really isn't the most basic problem.  What I think is more basic is the fact that we have decided that the things we can measure, and routinely do measure, are the important things, and we mainly base our studies on these pieces of data that we have decided are important because we can quantify them.

I recognize that medicine has, at times, significantly improved the quality and quantity of peoples' lives, so disrespecting it based on its fallacies is unkind and unfair. I would really just like to see my medical profession lighten up and recognize that much of what we see as fact is not. This could nicely dovetail with the recent emphasis on what is called "shared decision making." We have come a long way from the paternalistic past of medicine, and have another long way to go.

Wednesday, June 9, 2010

800 pound mooses and the American College of Physicians

The American College of Physicians has created an initiative to reduce costs and increase quality.  It is called the High-Value, Cost-Conscious Care Initiative, and was launched at the annual meeting in April.  They plan to focus on overuse and misuse of ineffective tests and treatments, of which there are many.  The congressional budget office estimates that 700 billion dollars yearly is spent on tests and treatments that do not improve health.  I suspect they underestimate that significantly. At the same meeting the college revealed plans to lobby for changes in health care policy not quite adequately addressed in the health care reform package, including prolonging salary bonus for primary care doctors treating patients on medicare and medicaid.

This is good! Even great. Why did this take so long?

I expect that part of the problem has been that it is difficult to find consensus in changing a system when there is considerable concern about loss of income and loss of respect. 

Issues not mentioned in the articles I have read about the meeting which are difficult to address include the fact that the present 10% bonus for primary care physicians doesn't come close to making the salaries of specialists and family practice or internal medicine doctors equal.  Providing adequate numbers of high quality primary care doctors is absolutely necessary to raise the quality of health care and health in general, and the oversupply of specialty physicians pretty much guarantees that too much expensive and unnecessary specialty care will be delivered.

Also, addressing the large and irritable moose sitting in the corner of the room during this discussion, some physicians really do make too much money.

I don't think that physicians should have to take extra jobs as cab drivers to support their families, as happens in Cuba, and there are many issues suggesting that physicians' salaries should be higher than average salaries, but a starting salary of $500,000 for a neuroradiologist is just plain out of balance. A full time primary care doctor can expect to pull in $150,000 at the height of his or her career, and in small towns or if the physician is female, that number is significantly smaller.

It is difficult to address this issue in a group like the American College of Physicians, because most people don't want to see their salaries shrink, and these large organizations are responsible for representing all of their members.

(Note: the 500 pound gorilla has been replaced with an 800 pound moose due to regional differences in fauna. i.e I'm from Idaho.)