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Saturday, March 30, 2013

What does American healthcare want?

I know what I want, in healthcare, that is. I want it to be efficient, effective, thoughtful and inexpensive. I want it to create healthy people who don't need very much health care. I want it to involve elegant solutions to problems that take less time, money and effort. I want it to be so much easier and less expensive that taking care of all of our people uses even less resources than taking care of only some of them, as we do now.

But the healthcare industry in America is bigger than me, and bigger than all of the doctors who work in it, even if we could all agree on what we want. So what does it want?

Is it even reasonable to think about healthcare as an entity? I propose that it is, that this way of looking at it makes the direction it has taken much more understandable.

We observe that bureaucracies grow, even though we complain about how they should shrink and become more efficient. Agencies beget more agencies, and attempts to reduce bureaucracies often don't work. I've seen what happens at our local university when educational budget cuts happen. They cut positions, but the people who remain are expected to pick up the functions of the ones who lost their jobs, which leaves the scope of the bureaucracy the same size as before, but temporarily overworks the people who remain (until they hire new people to unload them.)

The healthcare delivery system in the US has progressively grown, primarily driven by the growth of insurance, both government and privately funded. This has brought financial professionals heavily into the delivery of care, and has also increased the amount of money available for services. The availability of financial resources makes it more  possible to continue to treat patients who become sicker and more dependent upon it. It is also more feasible to develop very expensive technological approaches to illness, which expands the system to include scientists, device manufacturers and the companies with their own workers and advertising professionals. This just gets bigger geometrically.

Even if individuals within this vastly complex system want care to be cheaper and less complex and patients to be less dependent, the system itself does not want this, and continues to grow. It's hard not to invoke the metaphor of a large, stupid and perpetually hungry giant. Even without the metaphor, mathematics explains why complex, inefficient technological medicine that creates dependency wins out over elegant, efficient and cost effective medicine. The complex and inefficient version is bigger. By its nature it is bigger, which, in the absence of an external force deterring it in some way, or some catastrophic imploding event, means it will continue to be the bulk of what healthcare is.

So why even try to find the elegant solutions? There is abundant talk of implosion and the affordable care act has made some attempts to externally deter the growth of the healthcare industry. I don't see the former as happening anytime soon and the latter seems unlikely to have a major impact, but if we keep looking for ways to make healthcare be less expensive and more of what we, as patients, really want, those solutions will be available when we really need them.

Tuesday, March 26, 2013

23andMe: why might a person want to have their genes explored?

My son, who is 19, wanted a nice jacket and his genome for Christmas this year. He had found out that a company called 23andMe would tell him about his genetic susceptibility for diseases and his ancestry for only $99. 23andMe is a private company that started doing direct to consumer genetic testing in 2007 and has progressively lowered their prices and increased the amount and sophistication of information they give clients since then.

My sister bought my son the genetic kit and the padded envelope was under the tree for him on December 25th. He opened up the little plastic tube inside, spit in it and sent it back. In a couple of months he had all sorts of interesting information. He was most interested to see what parts of the world his ancestors sprang from, but also got information about scads of other things including his sensitivity to caffeine, ability to recognize bitter tastes, whether his muscles were predominantly "fast twitch" suggesting he would be a good sprinter, whether he would be sensitive to certain medications for which we have that genetic test, and whether he carried genes for some common conditions such as cystic fibrosis or hemochromatosis. With each piece of information there was a link to information about how good the science was that backed up the association, what the disease was and how common it was in the population.

23andMe got its name from the fact that there are 23 pairs of chromosomes in the human genome. Evaluating genes from a spit sample in this way was named invention of the year in 2008. It uses microarray analysis to look at single nucleotide polymorphisms (SNPs) via the company Illumina. (Illumina also provides its own service of full genome sequencing which is far more expensive than the $99 test that 23andMe performs.)  After submitting the sample, the client can fill out tons of surveys and questionnaires which the company can use to make even more predictions about characteristics based on SNPs.

It is possible to detect increased or decreased risk of certain diseases such as Alzheimer's disease, melanoma and breast cancer. There are certain SNPs that are associated with an increased risk of heart attacks when one drinks coffee. There are SNPs associated with higher risk of an adverse reaction to warfarin, statins or certain drugs for HIV or hepatitis C.

When I, as a primary care physician or hospital physician, see a patient, it would be incredibly useful to know what the person's individual propensities are. Is this the patient who should be watched closely after being started on a certain drug, or perhaps not started on it at all? Should further testing be done for cystic fibrosis, or is this very unlikely? Is this one of those people I should tell to drink coffee, because it is good for them, or are their needs different? I spend many hundreds of dollars of the patient's and their insurance company's money finding answers to these questions. Hemochromatosis is a genetic disease in which iron builds up in the tissues, causing arthritis, fatigue, diabetes, heart failure, skin changes, liver cirrhosis and cancer. It is pretty common, about 1/200 Caucasians have it, and it usually doesn't present until the fourth decade, often with some life threatening disease. By reducing iron intake and therapeutic removal of blood, iron stores can be kept at safe levels, completely preventing actual disease, but none of the most standard blood tests detect it when it is still early. A 23andMe test detects the most common genetic abnormalities that cause it. Using the tests that I order to detect it would cost over $600 the last time I looked into it.

Lately there have been many articles looking at the health benefits of drinking coffee and eating dark chocolate. We have a large database of nurses who drank astounding amounts of coffee and also participated in a longitudinal study of health outcomes. We don't know anything about these peoples' genetics, but we do know that, in general, the moderate to heavy coffee drinkers did better on many measures. Dark chocolate appears to have positive effects on blood pressure and other cardiovascular outcomes. One of the tests in the 23andMe profile is fast vs slow caffeine metabolism. It turns out that fast caffeine metabolizers may have reduced risk of heart attack when they drink coffee and slow ones have an increased risk. There are many reasons why a person might drink coffee or eat dark chocolate other than improving their health, but knowing about my caffeine metabolism would definitely have some effect on my consumption.

For a patient, there are so many terrible diseases out there vying for one's attention. Which should we focus on? The site has some very good generic advise for patients on what they might do to reduce risk for disease, since only a portion of that risk is genetic.

There have been many articles discussing the pros and cons of personal genomics. It is possible that detecting an increased risk of an expensive disease could affect insurance costs or willingness of a company to hire a person. Insurance discrimination based on this information is definitely illegal, and 23andMe information is kept secure, but anything anywhere on the internet is potentially common knowledge. Some people have been concerned that since the information is given directly to the consumer rather than involving a physician to interpret the results, misunderstandings could occur with unknown consequences. Genomic information is used as part of medical evaluations, including full genome sequencing for rare and mysterious diseases and characterization of specific mutations in malignant tumors to find out which of the many very expensive cancer drugs will work for them. This information definitely requires a doctor to order and interpret it correctly. The information a person gets from the 23andMe site is useful at some level for an educated consumer, but would be even more useful if shared with a physician. That process would take time and it might be challenging to get a primary care doctor to engage in it. If physicians became familiar with the format, it would be possible to review the information at a designated appointment for that purpose, as doctor and patient looked at the results together on a computer.  Because genetic data is difficult to interpret and explain, physicians often refer patients to genetic counselors, but these visits are usually expensive and time consuming and reserved for people with definite medical risks or recognized diseases.

Why, one might wonder, does it cost only $99 to get all of this awesomely useful information? Ordering any little part of this information, without the website support or geneology stuff, costs far more than if I, as a physician, order it for my patients. The low cost is at least partly because this venture bypassed the usual regulatory steps and isn't paid for by medical insurance. It is also not yet profitable, and was initially bankrolled by Google cofounder Sergey Brin, Genentech and some other investors. Because it gets more powerful information and becomes more efficient as it gets more customers, it is becoming progressively more profitable at the same time it becomes more affordable. There are other companies that do personal genomics, but I have been unable to find any that use this model and have anywhere near the level of success that this one does, so I don't think competition is doing much to bring costs down.

Today I got online and pressed the "buy now" button for a 23andMe kit. Soon my padded envelope will arrive and I will spit in a tube and wait for my results. Ninety nine dollars is a very small price to pay for a chance to know what my particular medical issues might be. So much of the evidence in evidence based medicine is based on the idea that the responses of a single person will be the same as those of an unselected population. Population based research leads us to believe that exercise, olive oil, coffee, dark chocolate, red wine, statins and fish are good for everyone, but are they, in fact, good for me? 23andme can't answer most of those questions yet, but if enough people are analyzed there eventually will be a better understanding of individual patient's needs.

As I re-read this post, after getting the initial comment (see below), I realize that it reads like an advertisement for this particular company. I do not intend that, but I really can't find other services that are comparable. There are lots of companies that are rolling out genetic evaluation products and I expect that in a few years there will be many viable competitors. Using genetic testing to individualize treatment is all over the doctor news this week. Eric Topol, a cardiologist and geneticist, spoke about it here. The practice of using genomics is moving very fast and it is impossible to know what impact it will have. It has the potential to increase health costs astronomically, or improve and streamline care. I am excited to see what a direct-to-consumer model can do, unconstrained by many of the perverse incentives that make medical progress slow and expensive.

Saturday, March 16, 2013

Is a high calcium diet and calcium supplementation bad for you?

An article from Sweden was recently published showing that in a very large group of women, over 60,000 of them, followed for 19 years as part of an also very interesting study of the effectiveness of mammograms, women who get more calcium, in their diet or as supplements, had a higher risk of dying of anything, but especially of heart attacks. It is unclear why this would be true, but there are various theories.

Further, the study showed that this risk was more pronounced if the calcium was taken as supplements, but still present in women who got their calcium from the food they ate. The highest level of risk was in women who got more than 1400 mg of calcium a day, and an intake of 700-1000 mg a day did not particularly increase risk. The women with the lowest average calcium intake were not at any increased risk of death, which was a surprise to the researchers. Information about calcium intake was taken from the subjects' reports of diet and supplement use, which was further validated by phone interviews of recent food intake. Since most women think that consuming calcium is healthy, I would guess that there was a tendency to overestimate calcium intake, suggesting that real risk may be present with lower calcium intakes than the study states.

This is big news. Or is it? No, it actually isn't. In 2010 the British Medical Journal published a meta-analysis  of studies of calcium supplementation in healthy people and concluded that there was increased cardiovascular death in those given supplements. There had previously been studies showing that calcium supplements in dialysis patients accelerated calcium deposition in blood vessels and increased cardiovascular death.

It has been part of our general medical wisdom for my many years of practice to recommend calcium, as food or pills, to our women patients. I remember several years ago when we began to be aware of the real impact of osteoporotic hip and spinal fractures in our aging population that physicians were encouraged to recommend to our post-menopausal patients that they take 1200-1600 mg a day of calcium. That was very hard to do. A cup of milk contains about 300 mg of elemental calcium, yogurt slightly more, cheese not much at all. Calcium fortified orange juice was about as much as milk. Dark green leafy vegetables contain calcium, but not a whole lot. A cup of collard greens, cooked, contains about 350 mg, but people rarely eat that much cooked greens. I would work through how to get all that calcium in the diet and usually suggest my patient take a chewable calcium pill for every meal they didn't eat something that was high in calcium. Luckily for my patients, I doubt many of them really did this.

Calcium supplementation seemed the right thing to recommend after estrogen, which is well known to reduce fracture risk, was discredited by the Women's Health Initiative due to what appeared to be an excess of heart attacks and strokes in treated patients. There were other medications for osteoporosis, but they had side effects and were really only approved for established osteoporosis, which most patients don't want to wait to get.

But why did we ever recommend calcium supplements at all? Did we have any good evidence that they worked? Sort of, but in retrospect, not really.

It does make sense, when you think about it, that calcium would strengthen bones. Bones are, after all, made mostly of calcium. Over the last 3 decades at least we have studied the effects of calcium supplementation on both bone density and on risk of fracture. We care most about risk of fracture, because bone density is just a test, and is not necessarily indicative of whether a person will break a bone. The most important kinds of fractures as we age are those of the hips and vertebrae. These are the ones that cause disability and death and are associated with the thinning of bones that comes to many of us with age, that is to say osteoporosis. Although some studies early on appeared to show that taking calcium, with or without vitamin D, reduced these important fractures, later analysis of all of the well done studies showed no benefit. There was even a suggestion that higher calcium intake might have been associated with more hip fractures. Many of these studies were done in the most scrupulous way possible, using double blind prospective methodology or correcting for factors that might make patients with higher calcium intake be those who were at higher risk of fracture in the first place.

What about vitamin D? Does this make a difference?  In the Swedish mammography cohort, vitamin D supplementation did not reduce the risk of heart attack or death that was associated with increased calcium intake. In a recent large study out of Finland from 2010, combining calcium and vitamin D had a slight but not statistically significant effect on fracture risk in a group of 65-71 year old women living in northern Finland. Vitamin D itself is the subject of lots of research and although it may be good to supplement it, especially in people with risks for low levels, it is not clear that it reduces the risk of fracture in the majority of post menopausal women.

So what is the bottom line here? It does appear that taking calcium supplements and deliberately pushing high calcium foods increases risk for death and doesn't save a person from disabling fractures. Doctors have so many things that they need to advise people about in a preventive office visit, getting exercise, quitting smoking, controlling their blood pressure, getting vaccinated against dread diseases. Now we just don't have to also tell our patients to drink milk and take large and unpalatable calcium pills. We should probably tell them if they are already doing that, to stop the pills and concentrate more on a healthy balanced diet, with plenty of fruit and vegetables and fish and olive oil. We can rejoice in having one less thing to fuss about!

Friday, March 15, 2013

Female feticide --ethical issues of ultrasound in India and China

The use of ultrasound has had a large impact on health care in resource poor countries. This article details some of the research that has been done overseas to look at the impact on bedside ultrasound by caregivers to deliver more appropriate care for injured and ill patients in Africa, Asia and Mexico. Using an ultrasound to determine how dehydrated a child is, whether an injured person requires surgery, whether a person who has collapsed has a blood clot or a punctured lung or fluid around their heart and treat those things appropriately is incredibly powerful and, after paying for the machine, costs nothing but the time to train practitioners.

It is possible to find some of the most interesting and cutting edge uses for ultrasound in the literature from developing countries because they have the equipment and, lacking CT scanners and x-ray machines, they have ample motivation to use it to its greatest advantage.

In India and China, however, which both need low cost alternatives for diagnosis and treatment, ultrasound use is regulated because of the common practice of using it to determine sex of the fetus and then to selectively abort female fetuses. In China, the one-child law combined with a preference for male children and led to female feticide and then laws to prohibit use of technology to determine the sex of the fetus before birth. Apparently the law is difficult to enforce and so sex specific feticide continues there. In India conservative estimates of the number of female fetuses aborted was about 250,000 per year.  There are campaigns by the government to encourage valuing female children, but the economic and social reasons that the problem exists in the first place are at the very basis of the issue.

When a woman in India is married it is still traditional to offer the family of the groom a hefty dowry. There are laws against dowries but that doesn't seem to have changed the practice much. Women also work at jobs which are less prestigious than men and earn lower wages. At marriage, a woman customarily moves to the home of her husband and is no longer available to take care of her own parents. So girl children are expensive.

It is much cheaper to get an obstetrical ultrasound in India than in the US, but still very expensive in comparison to overall cost of living. Getting an abortion is also relatively inexpensive, but costs money, which poor families actually don't have. It is far less expensive to have the baby and abandon it or kill it, and female infanticide is also pretty common in India. An article in the Atlantic Monthly looked at this problem and some strategies to deal with it, such as safe places where babies can be left, no questions asked, for adoption or care.

General Electric Healthcare, the company that makes the tiny pocket ultrasound that I use, and also makes a full range of amazing ultrasound equipment, was severely criticized and was even in legal troubles regarding the perception that they were complicit in sex determination of fetuses. This file describes their experience. Apparently they are actively involved in trying to enforce Indian law and have, according to some of my contacts, been less willing to donate equipment in India, which they had done before. The manufacturers are legally responsible for how their equipment is used, per a 2004 change in the laws about prenatal sex discrimination.

It seems to me that the attempt to regulate use of ultrasound in order to reduce the abortion of female fetuses is doomed to complete failure. It is just too easy to do an ultrasound and see a fetus's genitalia. An economically motivated family certainly can arrange to sneak into an ultrasound clinic and have a sympathetic technician figure out the sex of the baby inside. There are also genetic means for determining sex which are becoming easier and more affordable. Sex specific abortion, the actual procedure, is also illegal in India and China, and so a significant proportion of such abortions are done unsafely, risking the life of the mother. Women who can't afford an abortion often take pills or poisons to end their pregnancy, risking not only their own health but the health of their baby should it survive. Clearly most women understand these risks, legal and physical, and still attempt to terminate their pregnancies. Ending this practice will take significant social change, including abandoning dowry practices and improving the status of women in the workplace.

Saturday, March 2, 2013

Recycling the community physician: how should we really be training the next generation of doctors?

I have been spending time at an academic medical center lately and I’m noticing some obvious flaws in our method of shaping the doctors of the future. When I went to medical school I was trained by physicians who were eminent in their areas of specialty and also did some research. They taught in classrooms and as attending physicians when we were working on the wards as doctors in training. I realize now that the clinical attendings who helped us manage our general medical patients actually specialized in some more narrow aspect of medicine, but were smart enough to be able to manage a diverse array of medical problems.  I thought they were all amazing and never even entertained the possibility that their knowledge was less than exhaustive. I was also taught by the interns and residents who were themselves in training, though with an MD after their names. I thought that they were both wise and skillful. Perhaps they were. I will never find out now.

Watching the training of medical students this last month, I am appreciative of the skills and scholarship of many of their teaching attendings, but also am noticing that there is a difference between a physician who has spent his or her time entirely at an academic medical institution and a good community physician. The academic physician is nearly forced by the proximity of educational lectures and the demands of teaching to keep current on the recommended treatments for various diseases. They also rely heavily on the expertise of consultants in everything from dermatology to cardiology and gynecology,  so don’t necessarily have a good grounding in treating a whole person in the community and circumstances in which that person finds himself. In practice, it would not have been unusual for me to treat someone for their depression, congestive heart failure, obesity, cough and the rash on their legs. In fact, all of these problems were probably connected and required an approach that recognized the other issues.

I was also hanging out in a university hospital’s emergency department some of the time, which was fascinating and sometimes really hard to watch.  After saving the patients who required that acutely and sending a subset of them to the wards for admission and further treatment, there were patients who had issues that required a subtle or clever approach, which was not really in the knowledge set of the ER physicians. Not that it necessarily should be, since emergency physicians should really be dealing with emergencies. Still. Many of the patients who use emergency rooms do so because they cannot be refused service there for inability to pay, and they can be seen the day they show up, though they may have to wait many hours. Although their non-emergency problems should be taken care of by doctors in the community, they don’t have doctors in the community, and sometimes, if they do, those doctors are not particularly skillful.

So I think that academic medical centers need physicians who have been in practice to teach medical students. Physicians who have been in practice also need academic medical centers to remind them to keep their knowledge bases updated and give them a reason and a method for doing so. Academic physicians are very intelligent and hard working, but much of their brain space is taken up with their research projects and many or even most of them have never had to take care of as many patients for as long as those of us in practice have, and so they are not ideally suited to teach medical students how to practice medicine.  It would be nice to see some cross pollination between medical schools and non-teaching institutions. Community physicians do act as preceptors for medical students, taking them to clinic and on rounds, but this is just a small fraction of the medical students’ learning and is not coordinated with teaching objectives.

It was probably nearly the same when I was a medical student, but I never noticed, other than realizing when I got out of medical school that there was still lots to learn. One thing that was significantly different when I was in training was that in the 3rd and 4th years of medical school we had very important clinical responsibilities. Without us, patients would have died and residents would have been frantically overworked. We drew bloods, we wrote progress notes, we started IV’s, delivered drugs and blood products. We were at the bottom of the food chain, but we were part of it.  We were called “scut monkeys” because of the number of menial tasks for which we were responsible for. Now medical students have been mostly eliminated from jobs that are vital to patient care. They have restrictions on work hours, which is kind of good and kind of not so good. They can spend all day trying to find learning experiences, but are also seen as kind of a nuisance because they have no really important role. When they get their MD’s and become residents, they have all the responsibilities all of a sudden since the medical students don’t help that much. I think I was observing some of the more unpleasant results of burnout in some of the residents as they were deluged with work that they weren’t really prepared to do. Their fatigue impacted attending physicians who were required to do more than they comfortably could handle, thus reducing their ability and willingness to teach.

In some of the hospitals where I have worked consultants or representatives of hospital organizations have come in to identify work processes that are ineffective or inefficient. This is necessary in places that are not heavily subsidized (and academic medical centers are pretty heavily subsidized.) I sense that this focus on efficiency is not necessarily a part of academic hospitals, though my single recent experience is hardly an exhaustive survey.    HealthGrades released a list of the top 5% of hospitals in the US in terms of patient outcomes and patient satisfaction and it is not surprising to me that very few primarily academic medical centers made the list. UC San Francisco is not on the list. Neither is Johns Hopkins, Massachusetts General Hospital, the Brigham and Women’s Hospital or the University of Washington. This may have something to do with the fact that they provide services to very sick and often uninsured patients, but I don't think that is all of it. The processes at the university hospital where I have just recently been hanging out are very haphazard compared to other good hospitals in my recent experience. Some well thought out process changes could free up huge amounts of wasted energy in a place like this, which would likely make both residents and attendings have more time for teaching and good patient care. Perhaps medical students could even be brought back into the team as an underutilized labor source.