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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.

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