Search This Blog

Follow by Email

Thursday, December 29, 2011

How does Canada do it?

When I was at my marathon internal medicine update course at Harvard earlier this month, I sat next to a very bright physician from Tanzania who works as an internist in Canada. I am so glad I talked to her. I was really confused about the health care system in Canada, especially the meaning of "socialized medicine."

Canada has a publicly funded insurance program that pays for basic health services and covers about 99% of outpatient visits. Doctors, though, are not all on a salary through the government, which I thought they were. Most physicians receive fee for service, just like they do in the US.

What happens is that their "medicare" is much like ours, and pays doctors for seeing patients. I am not at all clear as to what a doctor can bill medicare for, whether Canada pays for things like management services not involving face to face contacts or that sort of thing, which would be really interesting to know. Some doctors are on salary through community health clinics like they are here, but my Tanzanian friend said that those who work fee for service are paid more generously and have more control over their schedules, so that is what she has chosen to do.

I asked her how Canada deals with the shortage of primary care internists, since I figured this probably isn't a peculiarly US problem. She said that for as long as she has been aware, Canada uses its internists as consultants to the family doctors who are the real primary care physicians. The internist may see a patient several times in a year, but will give recommendations for management to the general practitioner who is primarily responsible for the patient's care. She feels that internists are paid well and have good lives. They do also take call at the hospital and usually provide inpatient care, but most are not "hospitalists" per se, but more what we would call traditional internal medicine physicians. Internal medicine consultants, in order to be paid at a higher rate than general practitioners, must complete a 4th post graduate year, a fellowship in internal medicine, which is one more year than US internists do.

This sounds to me like a truly great solution to the problem the US is having with too few internists. As a consultant I could take care of many more patients, but be less likely to be burned out since those patients would have another physician to help care for them, and as a consultant I would not have to be available to every patient all the time.

Once again, it looks like another country has figured out a solution to one of our problems and if we were flexible we could just adopt it.

Being a hospitalist and watching our hospital get digital

Since quitting my primary care job 2 months ago I have been working at our local hospital as a "hospitalist". I take 24 hour shifts, several in a row, and during those shifts I am responsible for taking care of all of the patients admitted to the hospital whose doctors can't care for them in that setting. This ends up with me being a consultant for some patients who are particularly complex and time consuming and being the primary doctor for patients whose doctors don't have hospital privileges or are out of town or who don't have a doctor at all. I meet lots of interesting people and get to know them and do the diagnosing, communicating and treating that they need until I go off duty. For many of these people I miss being able to see the whole illness through, like I used to do. It is freeing, though, to know that my responsibility ends at a certain time.

My days vary from extremely busy, where I can't even answer a phone call from my family and have to keep multiple juggling balls in the air all the time, to relaxing, where I can talk to nurses about their vacations and pester the ultrasound technicians to show me how to do imaging. I can sometimes leave the hospital during the day if I need to do something, and sometimes I can barely find a moment to jam some food in my mouth, and don't get to sleep much at night. Our hospitalist program is just getting going and we are working on making processes in the hospital fit us. We are trying to standardize our documentation (admission and progress notes) and still are pretty haphazard with regard to knowing exactly what and how to bill. We are a small hospital so we have only one hospitalist working at any given time, and we rotate shifts according to the demands of our lives and the availability of other doctors to fill in. We fill extra spots with doctors in the area who do this sort of thing and doctors from further away who we get through a physician recruiter.

Many small hospitals just hire a group that provides hospital services to do the whole program, hiring physicians, standardizing signouts, billing and that sort of thing. This is expensive, since the hospital pays heavily for the administrative services as well as the doctors. If a doctor doesn't work out (and in our experience, that does happen) there may be some conflict between the hospital and the hospitalist company. It's very much like the difference between hiring a babysitter oneself vs using an agency. I am glad our hospital is doing it our own way since it allows us to figure out what works best for us and keeps the lines of communication simpler. If we can't fill our spots, though, I bet the hospital administration will get desperate and hire a company.

Next month I will be working at a hospital a few hundred miles away which is larger than ours and which gets its hospitalists from a large hospitalist company. I will get a chance to see how a big operation does this stuff, which may help our organization stay independent. I will plan to continue to work at least some shifts at our hospital which will help me share what I learn. I will be working 12 hours a day for 7 days and then will have a week at home to recover. I'll be doing lots of driving.

Tomorrow is the last day of a block of 4 shifts that I have worked. It has been really busy. I think that everyone waited until Christmas was over to get sick and come in to the hospital because I've hardly had time to breathe. I have met lots of great people though. What has made work in December particularly challenging has been the fact that our hospital just adopted a computer system to handle nursing, ordering, lab and x-ray data. We had been inching along in that direction, but finally jumped into the deep end and now we have no lack of annoying hassles to commiserate about. The system comes from the McKesson company and is called Paragon. Superusers have been working on this for much of a year trying to write the program so it will fit us, but like all electronic medical records, it is full of weird little bugs, crashes, lags and unexplained inability to access what we need at inopportune moments. Some people are slower than others and we have had support staff resign over frustrations with it already. But having watched what happened when my outpatient office went digital, this is not as ugly.

I look forward to 2012, especially sleeping late on Monday and turning off my cell phone, however briefly.

Tuesday, December 13, 2011

Blog maintenance issues

This month the stats for this site showed that there have been over 10,000 views since its inception about 2 years ago. I was bragging about this to my 17 year old son, a computer whisperer, who has very little patience for my relative ignorance of the digital world. He gave me some advice, sort of the "queer eye for the straight guy" variety of advice. ( Reference: "Queer Eye" is a reality TV show where gay men give advice on fashion and lifestyle to clueless straight men.) Apparently it is amazing that anyone visits this site at all, for a number of reasons. The first is "TL;DR"--too long, didn't read. All anyone sees when they visit this site is a wall of words which is probably quite overwhelming unless the visitor is pretty darn determined.

The second is that there is hardly anything to grab the eye. I went with the packaged blogspot formatting and haven't changed it at all the whole time I've been writing. It is really quite attractive, I thought, but maybe the furniture needs rearranging.

And third, there are no photographs. I was thinking that most of what I write is kind of abstract and doesn't lend itself well to photos, and also before this minute I hadn't even checked to see how to put them in.

Thus the beautiful Haitian woman from the island of La Gonave carrying the aluminum bowl of laundry on her head. She has absolutely nothing to do with this post, but she did teach me how to upload photographs. Perhaps with future posts I can experiment with including random photographs of nature or something gorey from work. I could also just leave it like it is.

Monday, December 12, 2011

How to lose weight, lower your blood pressure, have better cholesterol and live longer, all without me nagging about it

There are various things that appear to be good for people. These include maintaining a normal weight, or losing weight if a person is fat, drinking some alcohol, but not too much, quitting smoking and exercising. Doctors as a whole also believe that lowering cholesterol levels is good, and at my recent update in internal medicine course there was some good data that suggested that drinking coffee is a good thing! Controlling blood pressure is also very important.

Being obese is bad in a number on ways, increasing risk of getting cancer, increasing osteoarthritis of the knees, which in turn is responsible for quite a bit of suffering and death, and increasing blood pressure and heart disease. Diet changes can help, but unlike much of what I have believed, there is no particular diet that is better than other diets for everybody. One study looked at people attempting to lose weight using either a low fat or a low carbohydrate diet. The low carb diets are exemplified by the Atkins  and the "zone" diet, which are rich or unlimited in proteins, even fatty meats, but strictly control the amount of carbohydrates a person eats. When a person does not take in carbohydrates, such as breads or rice or pasta, or sugary foods, that person will begin to use proteins as fuel and produce ketones which have the effect of suppressing appetite. The low fat diet, on the other hand, has been ingrained in us for decades, and belief in its healthful properties has resulted in reduced fat everything, from milk to potato chips.  Although many people can lose weight faster with the low carbohydrate diet, after 10 years both types of diet are equally effective.

A study out of the United Kingdom demonstrated an average reduction in lifespan in moderately obese patients of 3 years. This means that a 5 foot 2 inch woman over the weight of 165lbs could expect to live 3 years less than if she were normal weight, up to about 130lbs.  Her life span would be 10 years less than expected were she 220 lbs. A person could expect to lose 1 pound a week of weight by either eating 500 calories less or exercising the amount it would take to use up 500 calories. On a stationary bike a person consumes about 500 calories exercising hard for 45 minutes, and heavy people use more energy to do the same amount of exercise as skinny people. It is more effective to both exercise and reduce calorie intake because the body can reduce its energy expenditures if it thinks it is starving, and conversely inactive people often find it hard to avoid inattentive overeating.

Drinking no alcohol at all appears to be associated with a shorter life, though long term controlled trials of alcohol drinking are totally impractical, so the evidence is not unassailable. There are many bad health outcomes associated with heavier drinking, more than 3 drinks a day for men and over 1 drink a day for women, but even heavy drinking statistically may be better than none at all! (Obviously this is only meaningful for populations, since an individual can drink him or herself to death and individuals do regularly do this.) Women who drink anything at all have a higher risk of breast cancer, but it is heart disease, not breast cancer that is the major killer of women, by a long shot, and drinking definitely appears to lengthen a woman's life.

Cigarette smoking has almost nothing, in fact I can safely say absolutely nothing, to recommend it as far as health goes. OK, I can imagine some scenarios in which cigarette smoking has probably saved someone's life. Perhaps once someone leaned over to pick up a cigarette and just barely missed being hit by a bullet, or avoided being bitten by a malaria carrying mosquito due to being surrounded by cigarette smoke, but in regular life cigarettes do cause heart disease, strokes, vascular disease, lung disease and cancers of many sorts.  The CDC reports that 1 in 5 deaths in the USA is attributable to cigarette smoking. Physicians are not very good at getting people to stop smoking, but there are various medications, including Chantix, budeprion and nicotine products that can significantly reduce cravings for cigarettes with very few side effects.

A gradual decrease in the amount of exercise that Americans regularly engage in is mostly responsible for our devastating epidemic of obesity which will lead to health care costs that we cannot even begin to imagine at this point. As little as 30 minutes of exercise a day for 5 or 6 days of the week can make a significant improvement in many health outcomes, ranging from preventing Alzheimer's disease to preventing heart attacks.

Elevated cholesterol levels, especially certain types of cholesterol, such as the LDL (low density lipoprotein) is associated with increased deaths from vascular disease such as heart attack and stroke. In some cases it may be a marker of bad health behaviors and bad heredity, but it also appears to be causative, and lowering cholesterol with lifestyle changes, weight loss or medications of certain types does reduce risk of these diseases. The most effective medications to reduce cholesterol are the statins (at least as far as we know) and every year another study shows that being on statins is good for some new thing. This information should be viewed critically since statins are hugely big business for pharmaceutical companies, but even I, a skeptic, admit that using these drugs (things like atorvastatin (lipitor) and simvastatin) probably saves lives, especially in those at high risk for early or recurrent coronary artery disease. Statins can, and often do, cause muscle pain and cramping, and combined with certain other drugs can lead to muscle breakdown due to interactions. In general, though, they are probably as safe as many over the counter drugs and herbal preparations.

Coffee, in the nurse's health study and in other well regarded studies, decaf or regular, and in large amounts, reduces risk of developing diabetes, improves diabetes control and reduces progression of fatty liver disease or hepatitis C to endstage liver disease. This is big. The effect is not tiny either, and if coffee were a new pharmaceutical it could be marketed for this indication. It would probably cost upwards of $20 a cup, though. Researchers have looked for negative consequences of coffee drinking for years and have failed to find any that are significant, other than that coffee can give one heartburn or a sour stomach.

Blood pressure should generally remain below 130/80, though medication treatment may not be indicated until the numbers go over 140/90 and the very old may do better with slightly higher numbers. There are a myriad of medications that work for this, but chief among them are mild diuretics, especially the generic pill chlorthalidone which has been around for decades. Ace inhibitors such as lisinopril are also very effective, and calcium channel blockers can be powerful. Sometimes combinations of these drugs are necessary. 

Diabetes is very common now and by 2030 is estimated to afflict 1 in 10 Americans. We could turn this around by changing our lifestyles to decrease obesity, but that isn't happening, so in the not too distant future, a sizable proportion of all patient visits will have something to do with diabetes. Good control of blood sugars with pills or insulin can decrease risk of complications such as heart disease, loss of sensation, blindness and kidney failure. Treating a patient with diabetes follows some pretty detailed guidelines laid out by the American Diabetes Association, and involves control of blood pressure, blood sugar, cholesterol and screening for early signs of complications.

Looking at the paragraphs above, it becomes clear to me that it is going to be really hard for primary care doctors to instruct their patients in all of the good things they should be doing to live longer and healthier, and I also note that many of the things that I've mentioned are things that I am not that good at telling patients how to do. I'm not great at getting patients to lose weight or exercise, though I think I do a pretty good talk. I can only get a patient to quit smoking if she already plans to do it. I can do the diabetes stuff pretty well, I think, but it sometimes gets forgotten as I focus on what the patient really wants me to help them with, such as some kind of acute or chronic suffering that they are experiencing. I haven't yet tried to get patients to drink more coffee. That may be easier, though having them drink it without cream and sugar may be tricky. High blood pressure treatment is sort of my bread and butter, but it is a task without much thanks since patients usually do not feel better on medications and don't notice the condition at all until someone measures it.

So what I was thinking is that maybe I shouldn't be doing all of this stuff. Maybe I don't need to be the nag, especially since I am not that good at it. I prefer to be the good cop, which means I desperately need a bad cop, or at least a charismatic motivator. What is so special about me as a doc that I need to do all of this counseling? Other people might be better at it and wouldn't need the broad training that I have to accomplish a good 90% of the stuff I laid out. Posters, TV commercials and education in schools could much more effectively beat into peoples' consciousness the importance of diet and exercise and not smoking or quitting. Exercise and life coaches can be awesome motivators. The alcohol industry could be tapped for the funds to advertise the health effects of moderate alcohol, and I bet they would do a darn good job of making the point that alcohol is good for us. Some level of industry/public health cooperation could make sure that this didn't move into the realm of "a little is good so more is better." Diabetes treatment, at the level of periodic visits and medication adjustments, is much better done by a multidisciplinary team, including nurses and pharmacists, and not heavily dependent on physician input. Much of control of blood pressure could be done after home monitoring by a nurse or a pharmacist with a decision flow chart for which drugs to use, and I honestly think they would probably do a better job than I would. If things got dicey, the patient could come to me and I could sort things out. Cholesterol would be the same issue. The drugs to treat cholesterol are pretty limited, and with a fingerstick test at the pharmacy of at my office, medications could be prescribed per a protocol and the patient could be monitored until the dose was correct. Pharmacists can certainly monitor for drug interactions, at least as well as I can. What about the patients who don't want to do all of these good things? I applaud them--not everyone should be a sheep. As the good cop, I doubt I would be much more effective than my somewhat less extravagantly educated colleagues at convincing them to toe the line. If it was really important, I could of course give it a try.

If much of this public health and protocol driven medicine were not my job, I would have more time to sit down with a patient with complex medical and psychosocial issues and work with them to come up with solutions to problems. I could diagnose their fascinating and disabling diseases, inject their swollen joints, see them the same day they called in with a cough and a fever or blood in their bowels or vomiting or a suspicious lump. I could be a doctor, not a cross between an accountant and a mother hen. I, and my colleagues, could begin to see clearly towards being able to take care of the genuine needs of the scads of patients already in need of primary care, and those who will, if all goes well, be insured by 2014.

Wednesday, December 7, 2011

Harvard Medical School Internal Medicine Update--Deepak Chopra and more

Having now attended 4 of the 6.5 days of the Harvard Internal Medicine Update CME I am now more grateful for being here. The first day of talks was disappointing, with some of the presenters actually pretty much reading their notes word for word, which I could have done in the comfort of my own home. But many of the speakers since then have been more confident and have been speaking from their hearts and their experience and there has been more to think about.

Yesterday Deepak Chopra gave a special 2 hour lecture about the meaning of life which was quite moving. He is a physician turned writer, though reading his biography it looks like he was always destined to do things that didn't fit comfortably into the medical profession. He started as a medical student in India, went on to become an endocrinologist, was involved in Transcendental Meditation and was a follower of Maharishi Mahesh Yogi, learned Ayurvedic medicine and now is able to span the gap between alternative medicine, established allopathic medicine (what I do) and leave his toes dipped in the positively way-out-there, publishing books and even the occasional article for the New England Journal of Medicine. As a speaker, he probably makes boatloads of money, and spoke to us because his brother, Sanjiv Chopra, a gastroenterologist at Harvard, is the organizer for this course. The talk reminded us about the incomprehensible vastness of the universe and the math and physics which describes that. He described some advances in mind-body medicine, including some data that the genetic markers of aging can be partially reversed by a lifestyle that includes meditation, enough sleep, and a generous helping of peace and joy. There was a brief guided meditation that was delightful, followed by a description of what actually might have happened in our brains during that process. It was gratifying to see such a variety of physicians, who can sometimes be pretty concrete, especially as a group, listen and participate. My take home message included realizing that I shouldn't take myself too seriously.

Today, the first half of the morning was devoted to leadership, which the medical profession can sorely use more of. Four different speakers talked talked about their favorite leaders and what they felt made them particularly effective. They talked about some very significant changes that Harvard had made, as a health care delivery system, and how they did that. It took humility and a sense of humor for the world's best medical school/hospital to recognize that it had problems and to also recognize that making changes could come some distance towards solving them. Like most hospitals, Harvard has trouble making patients feel supported, communicating with families, coordinating care between different caregivers and deciding what care they, as a community, wanted to be giving. They had trouble making sure that frail elderly people didn't go bonkers in the hospital due to weird sleep cycles and changes in activity and medications and stimuli. The process of improvement involved convening groups of people from all levels of service delivery, from janitors through nurses, social workers and physicians, to come up with plans that then were tweaked relentlessly and evaluated constantly until they started to get them right. One example they gave was the diabetes center associated with the Harvard health system, the Joslin Diabetes Center. It wasn't providing consistent diabetic education and despite helping to develop guidelines for care, wasn't actually achieving those guidelines with their patients. They found that by having a team approach, centered on patients' needs rather than on doctors' preferences, they were able to get patients in to be seen much sooner and make everyone, eventually, happier, though not without significant gnashing of teeth.

One of the things that the Joslin Diabetes Center does is to make sure that the first visit for a diabetic involves teaching and an eye exam. Usually our diabetics wait for an appointment and then have an eye exam with an ophthalmologist who may or may not give appropriate feedback to the primary care doctor about the eye findings. Diabetics can become blind with because of changes in the blood vessels after years of elevated blood sugars, that can burst, destroying the retina of the eye. If the changes are caught early, laser surgery can coagulate the abnormal blood vessels and save vision. There is a machine that can photograph the retina without the patient seeing an ophthalmologist which is right in the diabetes center. It takes a few minutes and does a better job of screening the retina than a real human. So far it can't be billed to any of the public insurance companies. One participant in the class asked how it was paid for, and I could see that was a sore spot with the speaker, because it really wasn't paid for. I suspect that the patients who can afford to pay do, and those who can't don't. It is clear that technology like this is a great idea. It is also clear that the only way technology like this will be adopted and not add to the burden of costs for medicare is for medical care to be paid according to results rather than "fee for service" as it is now. I suspect that if costs for work like this were not directly handed on to a third party payer, machines like the one that images diabetics' retinas would quickly come down in price and complexity.

Much of what we have been hearing about is state of the art by specialists in the different fields that make up internal medicine, delivered by specialists. This gives us a much more in depth level of understanding, but also presents a standard of evaluation that is way more detailed and time consuming than even the most thorough of general internists could produce. Most of the physicians attending the course are general internists in non-academic settings, and many of us are under horrendous time constraints which are getting more horrendous as the primary care shortage progresses and payments tighten. Even though fee for service is on its way out the vast majority of physicians still practice that way, which means that to make the same amount of money that we used to, we have to see more patients, and with increasing insurance and government oversight to assure quality, we have to do more things with each patient we see. I don't practice that way, but most physicians do and are burning out. One doctor got up and told the presenters that she worked in the Bronx with a patient population that is very poor and high needs and she is expected to see 30 or more patients in a day, with no support from nurse practitioners or physician's assistants, and that even though she wanted to change her systems to make them work better, she just didn't have the time to start the process. If she wasn't so committed to her patients she would quit, but she can't imagine what would happen to the system if she did. It is more than sobering to realize that people like her will likely be expected to bear the brunt of the huge increase in diabetics that are coming out of adolescence, large colas in hand, along with aging baby boomers and the newly insured and also take up the slack as thousands of primary care internists retire with nobody to take their place.

It is clear that a herd of physician leaders are going to have to pull their heads up out of the writhing mass of needy humanity, stop seeing 30+ patients a day, and build systems that reduce waste, not only as far as spending on unnecessary testing and procedures goes, but also allowing physicians to do the things that it takes a physician to do, not be involved in busy work and things that we are not good at doing. It will be necessary to design ways to allow patients to use technology for what it is good for, and the medical profession so definitely can't shy away from social networking and digital communications for those patients who can work that way. And if we don't want to waste still more time and energy and human power trying to bill for each one of these communication steps, the payment scheme will need to change. And all of this has to happen REALLY SOON.

There is one thing about the talks (the ones about the nuts and bolts of medicine, not the leadership ones) that continues to disturb me. It is the "evidence based medicine" piece. There is a tendency by the speakers to stick closely to recommendations for therapy that are based on research trials with large populations of patients, getting away from telling us about what they, as individual skilled physicians have seen and done successfully in their practices. Clearly both the science and the experience deserve airtime. But worse than just presenting the studies is a little pervasive lie, or really more of a misapprehension, that accompanies the presentation of the data. The speaker will say, "in the CHARM trial of heart failure in patients with diastolic dysfunction, Candesartan did not reduce the endpoint of hospital admission or death. So you see candesartan just doesn't work in these patients." Yes, but no. In the study, a population of these patients did not get significantly better, but that doesn't mean that the drug doesn't work on our individual patients. I'm sure that when individual patients were evaluated it worked very well on some and absolutely abysmally on others, in fact it might actually have killed some of them. Which is also true for the drugs that did work in the clinical trials.  Saying that a drug does work or doesn't work based on a clinical trial is incredibly misleading and encourages us not to believe our patients when they say "Doc, that stuff really helped" or "I stopped it after a week because I got much worse." Patients often do know how things affect their health. There are many variables in our patients that govern what works for them, and studies do their very best to reduce these variables, making them more reproducible but less relevant to the treatment of real people.  It is valuable to reduce a problem to measurable parts and then perform an experiment because it makes it possible to interpret the data and then allows us to make an educated first approximation about how best to treat our patients. Until we are able to genetically and environmentally define all of the characteristics that make up a human, however, predictions based on our population based science will be inaccurate.

Monday, December 5, 2011

Ranting about continuing medical education, evidence based medicine and cost ignorance

I am attending Harvard Medical School's yearly internal medicine update this week. In a little over 6 days we experience 62 hours of medical education, sitting for 12 hours each day in the conference room of a shiny glass and steel hotel in downtown Boston. We hear world authorities on diseases of all of the major organ systems tell us what they think we ought to know. I am two days into it and still pretty excited, but losing a bit of my enthusiasm.

Most of the presenters follow a set of power point slides, sometimes word for word, that are reproduced in our course syllabus in a size that is nearly entirely unreadable. The form of the talks is to present the scope of the problem, then the recommended testing and treatment, interspersed with the research that is the basis for the recommendations, with an occasional cartoon or anecdote. There are also brief question and answer sessions and cases presented with recommendations on management. There are audience response handsets so we can participate in multiple choice questions, in order to keep us awake and focused.

Each of the presenters is a specialist, the worlds expert on irritable bowel syndrome or sleep apnea or one aspect of liver disease. They teach us how to treat the problems they see as the final go to doctors for the entire world. Some of the diseases are common, but we are encouraged to entertain a differential diagnosis that includes diseases only seen a few hundred times a year. Most of these I have heard of at some time, but could only really say what organ system they involve, not what they look like or how they are treated. We are taught the treatments that studies show work, at least for a proportion of patients. We are taught the 10 blood tests or imaging studies that we should never forget to order if we don't want to miss something. They mention that they realize that we, as general internists, have limited time with each patient, but rarely do they tailor their information to make it practical for us to achieve in a patient visit. They haven't been doing what I love to see clinical teachers do--telling us what they know to be true from their vast experience. I think that the emphasis on "evidence based medicine" has made them doubt the value of their hard won wisdom.

A few of these excellent clinicians have, however, been starting to talk about limitations of population studies to guide therapeutics. One oncologist said that different types of cancer will eventually be seen as collections of "orphan diseases".  Orphan diseases are usually considered to be rare diseases that are well described, but not prevalent enough to warrant as extensive research and treatment development as diseases that are more common and have more of a social impact. What this oncologist meant is that each cancer may have slightly different genetics in different individuals, leading to very different responses to chemotherapies or other treatments.

He gave the example of a new treatment for a cancer that completely melted away bulky metastatic disease in one of his patients, based on a genetic predisposition of the cancer cells in that particular person. I have seen this kind of thing on several occasions. One of my patients is completely free of melanoma nearly 20 years after receiving a cancer vaccine in a trial that failed. The study showed it didn't work. Except that it did, in my patient. She had had a recurrence of her melanoma, in a lymph node, which is nearly universally fatal and pretty much untreatable. It went away and she is alive now with no evidence of disease.

Most of the rest of the researchers have not mentioned, though, the fact that different genetics and maybe environments make this "orphan disease" concept true for other common ailments. We are taught that diabetes is best treated with a certain drug first, then another can be added and so on, but anybody who listens to their patients knows that although it is right to start out with certain guidelines, some patients do terribly with drugs that should work and do great with drugs that are bad. There are drugs that are good for people with heart failure, make them live longer and go to the hospital less, except that in some patients these drugs make them sick or even kill them.  Population studies are just not very good for helping us navigate this kind of water. Anecdotes from colleagues with a wealth of experience are, though.

I am also disappointed, again, as I often am in this sort of situation, but the complete lack of awareness of the cost of the therapies and diagnostics by the clinical teachers. Maybe they are aware, but they don't share that information. In the rare cases where they do share some cost data, the numbers are left in some raw form that doesn't give us useful data as to what cost our patients or their payers will see. A radiologist presented some information on new imaging tests which are stunningly beautiful and potentially very useful. He said that he was aware of how radiological testing was overused, leading to unnecessary and harmful radiation and unsupportable costs, but gave no indication about how that information would be integrated into potential use of his new technologies. An oncologist told us that the cost for a course of chemotherapy for metastatic colon cancer that might give a person 2 more years of life compared to the older chemotherapy cost over $30,000 compared to $60 for the old stuff, but didn't say how many courses a person would get in a year. Letting us know this kind of data should be standard. We want what's best for our patients, but we need this kind of data to help counsel people who shoulder at least part of these costs.