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Thursday, December 7, 2017

Charitable Giving (Plus musings on the 2017 tax reform plan)

'Tis the season

Every year at about this time piles of mail comes to my box asking for money. I look through the pretty envelopes, some with calendars and return address stickers, some with wrapping paper and greeting cards. Some have cleverly glued nickles or plastic membership cards so I can't recycle them without opening them. Occasionally there is an organization which has devised a new model of charity and I'm glad I looked a little further.

Giving to charity is a privilege which I have because I make more money than I spend. Not everyone has that luxury. Doctors, as a profession, are much better paid than most people in the world. We may have educational debts to pay off, but eventually we usually end up in the happy minority of people who have enough stored value to take care of themselves and their families and to feel secure if they live awhile past retirement. John F. Kennedy used to like the quote from Luke (this is the passage from the New Standard Revised Version, not JFK's) "From everyone to whom much has been given, much will be required; and from the one to whom much has been entrusted, even more will be demanded."

What is Money?
Recently I have come to have a different view of money than I had before. Money is just one way of storing value. It is convenient because it is usually lightweight and durable and it is now possible to represent it digitally, using credit cards or phones to transfer it from one entity to another. It is liquid, meaning that it can be quickly turned into something else like groceries or clothes or medicine. It also does no work while it is sitting around waiting to be used.

There are other ways of storing value which actually do work or give joy or provide comfort. These are usually not as liquid. Examples are stocks, which are ways of giving some kind of company capital for achieving some goal while expecting either a dividend or increase in value of the investment in return for tying up money. Stocks can be sold freeing up money, but the value of a stock is tied to the success of the company and so value stored as stock is volatile. Property is another way to store value. Property can provide a place to live or farm or be rented out for an income. It is not nearly as liquid as stock. Selling property takes time and is never a sure thing. Its value of can also go up and down. If it depends on things that grow on it or are built on it, fires and change in weather can profoundly affect its selling price.

Why not just put it all under a mattress?
The best value storage would be something that makes us happy, was a safe bet and could be turned back into cash whenever we needed it. The most durable way to make me happy is to make my family, my community and the world flourish. Here are some of the ways that this can work:

1. Invest in education: when I educate myself I become more productive. I get happier, better at what I do and when I am better at what I do I am less likely to burn out. I put as much money as I can into my children's education. It turns out I have kids who will turn education into value. This is fortunate. Having happy productive kids is an investment that is liquid, safe and makes the world a better place. There is a community music school in Concord, New Hampshire that pulls people of very different backgrounds to make good music so I support them. I also don't hesitate to donate to scholarship funds and would not vote against a school bond. I support candidates who support public education.

2. Invest in places to love and live: it made sense to buy a place for my kids to live rather than having them rent. The value of the property may be volatile, depending on who wants to live in that place in the future, but that investment provides shelter and a place for people to gather and make community. We have done some remodeling to make our house more accessible when we get old and wobbly and to make sure it can hold many visitors. The monetary value of these things may be unsure, but the real value is solid.

3. Charitable giving: giving money to organizations that share my vision for a more equitable and peaceful world is actually more of an investment than a gift if I do it right. Long ago I heard about a charity called the Potato Project. It is defunct now. They found food that would go to waste because it was surplus and routed it to places that needed food, nationally and internationally. It must have been really difficult, what with the fact that things like potatoes were perishable and that they had to deal with many different organizations, but I loved the idea and gave them money. Now there is a local project that has made national headlines called Backyard Harvest which gleans extra fruit and vegetables from local sources and distributes them via food banks and other programs. This combines community cleanup with a chance for adults and children to get out and do physical work together in order to provide really nourishing food for people in poverty.

Decades ago a the Heifer Project sent me a request for money. It was a novel charity that bought a farm animal for a poor family, trained them how to care for it and expected them to give one or more of its offspring to another family in need. This had a kernel of an idea that has become another excellent charity idea. Microlending including such organizations as FINCA provides low or no interest loans to people who want to start a project but don't have the capital to do it. The ones that got my interest initially were international, primarily lending to women who didn't have as much access to cash as men and tended to be more hard working and financially dependable. There are microlending organizations in the US as well, some of which even service the loans and give the investor a return on their money. When I was in Haiti in the tiny village I sometimes visit to help with farming and health projects, the community had started their own microlending bank, with no donated money, just a little cash box and ledger books. People who had next to nothing put money in, knowing that someday they might need to borrow some for a project or an unexpected death or illness. Money that we donated made it likely that more people could benefit from the loans, but the project was clearly self sustaining. Having this option for people in need means that when we go back, the community will be healthier and the limited money we have to donate will go to projects that can best benefit.

I like to give money to organizations which protect the environment. There are many ways to do this including the Environmental Defense Fund which engages in legal battles and the Sierra Club which has a myriad of projects. I like the approach of the Nature Conservancy which simply buys land to preserve it. That's a pretty expensive way to save a place, but it works. Locally we have The Palouse Land Trust which buys and protects local land from development. This makes it possible for everyone who comes here to walk in the hills and appreciate how amazing they are. We have the Palouse Clearwater Environmental Institute which teaches people about environmental issues and does stream and trail cleanup, has sustainable energy projects and more.

I give a large chunk of money every year to the Unitarian Church I attend. It sounds corny to give to a church, but it makes excellent sense. Without donations, the Unitarian Church would not exist. It has no product for which it charges and its services are free. It provides amply to the community by being a place that productive and concerned people get together to make good projects happen. It makes music in a way that everyone participates. Participatory music is one of the oldest ways that humans have bonded and it doesn't happen in many other settings. It provides counseling for people in trouble and mobilizes resources for people going through hard times. It makes people think about the big issues and pull away from the cycles of worrying and isolation. It needs to pay for heating and electricity and salaries of the people who work there. Walls must be painted and carpets cleaned and coffee must be bought and associated projects supported. The overhead is essentially nil. Every dollar that I give goes to something that matters.

I am associated with a Zen organization in Santa Rosa California whose teachings I benefit from, which means that my patients and my family and friends also benefit from them. Like my church they have no way to make money other than donations, so I donate. With money, peace and wisdom efficiently diffuses via wiser more peaceful students, without money, not so much.

Some of my charitable giving is in funding trips that I take to South Sudan and Tanzania to learn about their healthcare, teach ultrasound and treat patients. These involve large chunks of change, but they are the most clearly positive way I can contribute since, although the visits aren't necessarily sustainable, the teaching and learning are gifts that keep giving. The organization that supports the hospital I visit, Sudan Medical Relief as well as Doctors Without Borders needs money to keep doing what they do, so they get donations as well. A fully local Haitian group (Farming is life = "jadin legim se lavi peyizen") which provides community resources for farming and health gets a stack of cash when anyone I know visits, since they have no reliable way to get money from remote donors. Their work is essentially without any overhead or waste and completely self governed. Since the cash economy is not healthy in the little island of LaGonave it is difficult for a project to be truly sustainable at this point. 

There are charities that I used support and don't anymore, mostly related to my experiences overseas. I used to give to organizations like United Way and the Red Cross. I am sure that they do good work, but I don't know where the dollars go. I do know that money from large organizations with what appear to be deep pockets doesn't necessarily go to projects that sustain themselves. Overseas money is often diverted or spent to do projects at foreigner rates which are much higher than local rates. Donations are best when they act like a lever to make a bigger impact down the line, like a microloan to a small entrepreneur who creates a vibrant business rather than an overpriced bandaid on a preventable injury that will fall off in a few minutes.

The 2017 Tax Bill:
Recently a tax bill passed the senate which does various things with which I disagree. An under-recognized negative aspect is that it discourages people from "itemizing" by removing several ways which people can claim deductions and by increasing the "standardized deduction" which is available only to people who do not itemize. Itemizing is the way that people get a tax deduction from charitable contributions. When I itemize, I do not pay taxes on the money that I donate to charitable organizations. I will continue to give enough in charitable contributions that I will still be better off itemizing than taking the standard deduction, but many people will not. Itemizing has been a traditional way that people are encouraged to give to charity when they move toward being financially comfortable. Giving to charity has meant paying less in taxes. Often taxes pay for the same things as charity, but in a more roundabout way and far less efficiently. The opportunity to give to newer, more sustainable and efficient projects is up to legislators who may have very different priorities than individual taxpayers. I worry about the impact on organizations that are supported by charitable giving.

Overall I would encourage those who have become financially secure to turn stored value into things that sustainably create joy not only for ourselves but for the wider world. Give generously so that it is more than obvious that you should itemize, regardless of what deductions are pinched off. Spend generously on education, your own, your children's and through scholarship funds. Find local groups that have models of giving that you appreciate and give time as well as money. Give, as they say, until it feels good!

(Feel free to comment with other charitable organizations that you think are important to support. The projects I mention are in no way meant to be complete. For instance, I entirely forgot to mention Habitat for Humanity which is a great organization.)


Monday, October 23, 2017

Technology is unkind to the elderly


In about 1990 we got our first computer. I say "we" because my husband and I shared a desktop which I used infrequently. I mostly used it for word processing, and the internet was very young. At the turn of the millenium, my children were using computers and they were limited to 1 hour of computer time a day, which was on a shared desktop. By 2001 I was communicating with my grandmother, then in her late 80's, by email.

My grandmother had received, probably just prior to the millenium, an email machine from her son. It was a little thing on which she could type messages to a dear friend who lived in London. She loved the ability to spontaneously send him a message and get an answer in a day or less. She was a retired reference librarian and had worked in the Bay Area school system where an exhaustive knowledge of the Dewey Decimal System allowed her to connect students to the resources they needed. We thought she would be delighted to have an Apple Macintosh. With such a thing she could query the world of data and feed her insatiably curious mind.

This gift was a failure. Nothing about it was intuitive. Scrolling, clicking, using a mouse, returning to a previous screen, all were lessons that she had trouble learning. She would call one of us or her son when the screen inexplicably looked different than it had and she couldn't find her way back to something familiar. I think she started to die a little when she couldn't make that pretty white computer work. In retrospect she just needed the email machine.

A few years ago my father, now in his 80's, gave me an iPad which he had bought and didn't use. By guess and by golly (as my grandfather would have said) we managed to navigate its passwords and get it transferred over to me. It was cute, but certainly no more useful than a laptop, and rather delicate, so I gradually broke its screen and then it was stolen when I was in South Sudan. On a recent trip, my father showed me his new iPad, which he also didn't use, which he thought I might have use for. He had been seduced into buying it at an Apple store and, likely with the help of some bright millennial, had entered a new password and the answers to some security questions. Being wise, he didn't write the password on the machine itself, since he knows how important password security is, so it is gone. Also, having had a long and very complex life, the answers to the security questions were subject to shifting interpretation. Although he and I contacted customer service, there is no remedy. The pretty iPad with the retina display is now an attractive coaster or possibly something under which to press flowers. (Those of you with a penchant for problem solving will ask about "return to factory settings" or even "jailbreaking." I will just tell you that, after trying these things for 2 hours with someone of legendary computer cleverness, Apple has those options pretty well blocked.)

Technology, by which I mean computers of all sizes including phones and tablets and the like, offers incredible potential to people as they age. Music can fill their ears, raise their spirits and help them to frame their lives as brave and glorious. They can see pictures of far off places which they might not be able to visit again, talk to children and grandchildren while seeing their faces, access reminder notes, pay bills, review bank accounts, donate to charity, play games that tweak their brains in good ways. Computers, at their best, make our worlds larger and extend the capacity of our minds. This is just what we need as we get older. But computers, with their infernal passwords and vulnerabilities to security breaches, their little bitty buttons and sometimes tiny screens, their failing wireless modems and misleading advertising, are making the old feel older.

By the age of 85, about 1/3 of people have Alzheimer's disease, per the Alzeimer's Association. This, of course, vastly underestimates the proportion of elderly people with some kind of impairment in their memory, problem solving or ability to learn new tasks. This group of people need, more than we younger folk, to have access to their medical records and to use the wealth of online resources to remain healthy or monitor diseases. It is precisely the group whose health can most benefit from computers and the internet who are left out. Almost all of the elderly patients I see in clinic decline to use the computerized patient portal. Although I think that the portal itself is pretty easy to use, it is the many steps involved in getting to the portal that are daunting, so much so that our older patients hesitate to even try.

In the UK in 2012, the Prime Minister issued a challenge to make the country more friendly to patients with dementia. This included a Dementia Friendly Technology Charter. The Challenge includes making workplaces and communities more kind to people as their brains age, but also to help them get some benefit from technology. There are quite a lot of technological solutions to the problems of dementia, especially for caregivers, but I don't think that producers of hardware such as computers and tablets are stepping up to the plate. It is perfectly possible to create an iPad that doesn't depend of remembering passwords and reduces vulnerabilities to abuse while allowing users to access music and video chatting and photos and information. The UK has made some headway toward dementia-friendliness. The United States has no such challenge in place and from my vantage point, people are just becoming more marginalized as they age.

I would like to encourage the hugely successful producers of technology to respect their elders to the extent that they create products that will welcome them. The makers of software that is useful enough to become a necessity should think twice before requiring that users have excellent memories. And until our technology becomes more friendly, companies should develop remedies so that people who develop dementia (or have brain injuries) are not effectively shut out.

Sunday, October 8, 2017

How much do we love guns?

A letter written to JAMA (Journal of the American Medical Assn.) by Robert Tessler MD and colleagues at the Harborview Injury Prevention and Research Center in Seattle presented evidence that the United States'  approach to guns has significantly increased deaths from terrorism.

Using the Global Terrorism Database from 2002-2015 they found that, compared to Canada, Europe, Australia and New Zealand, The US has a considerably higher percentage of terrorist attacks that used firearms and firearm related terrorist attacks were more deadly than any other method, including bombs. Of the 2817 attacks in that time period, only a bit over 9% used guns, but these attacks were responsible for more than half of the fatalities.

It's not just terrorism that is more lethal using guns. Suicide attempts are much more successful if they are made with a gun. In fact, over 80% of suicide attempts made with a gun are effective compared to only 1.5% with drug or poison ingestion. Over half of suicides in the US are achieved with a firearm. Suicide is the second leading cause of death for Americans between the ages of 15 and 34.

Gun ownership is considerably higher in the US than in any other country in the world. We have 112 guns for every 100 people. The next runner up country is Serbia with 58 guns per 100 people and Tunisia has the fewest guns at 1 per 1000 people.

Citizens of the US appear to love their guns. Not everyone, but as a nation we are clearly very enamored. Our second amendment, standing right behind the first which grants us free speech,  allows for "A well regulated militia, being necessary to the security of a free state, and the right of the people to keep and bear arms." This was interpreted by the Supreme Court in 1939 to mean that there was a collective right to bear arms, as would be required to have a state militia, and so a law to make sawed off shotguns illegal was felt to be constitutional. In 2008 the Supreme Court interpreted the second amendment to mean that people had an individual right to bear arms and struck down a Washington DC law prohibiting ownership of handguns. Since that time states have expanded gun rights including, in some, the right to carry a concealed weapon without a permit.

There are federal laws that limit gun ownership, preventing some criminals, drug abusers, spouse abusers, children and felons from obtaining them, but state laws are spotty and many people who use guns to commit crimes obtain them legally. There are classes of weapons that people are restricted from owning, based on the idea that there is no reason for a law abiding citizen to need a machine gun or rocket launcher. The strictest of laws which prohibit gun ownership in some countries would be found unconstitutional in the US, but most Americans support some sort of increased restrictions on gun ownership. Taking peoples' guns away is neither practical or legal, even if a majority of citizens felt like it was a good idea.

People who love guns do so for various reasons. The primary quintessentially American reason is that we feel like it is important to have some physical way to prevent our federal government from controlling a helpless population if that government ever goes over to the dark side. I'm not sure this is really realistic given the very advanced weapons systems and surveillance that the military has at their disposal, but I suppose we could strategically make trouble in a guerrilla warfare sort of way.

There are hunters who like to have rifles of various sorts for sport. There are gun enthusiasts who just think that guns are incredibly cool and love the technology. There are civil war re-enacters who love their classic weapons. There are people who live in dangerous areas who believe that having a gun could deter an intruder. There are people who live in Alaska who very realistically know that a grizzly bear is probably watching them when they hike and may decide to eat them. There are also criminals and violent gang members who want to have guns so they can shoot and kill people.

For dozens of reasons, people in the US love their guns. Because of this we have lots and lots of guns and the guns get used to kill children, concert goers, rivals, wives, husbands, lovers, innocent bystanders, congressmen, police officers, the unfairly and fairly accused, newlyweds and so on. We may love our guns, but most of these deaths are intolerable tragedies. Do we really love guns so much that we are able to tolerate the over 36,000 deaths per year due to them? It appears that, since we have so many guns, people tend to use them. (Go figure.) Do we really need so many guns? We seem to have agreed that certain dangerous people should not own and carry guns. Can we just enforce those laws more effectively?

Seattle, according to an article I just read, has enacted a tax on guns and ammunition. This is a creative and constitutional way to address the sheer numbers of guns in circulation. They charge $25 in taxes per gun sold and 5c per round of ammunition other than 22 gauge which is only 2c. This has been repeatedly challenged in court and has so far stood up. We have also done this with cigarettes (which are responsible for over 10x as many deaths, but usually after protracted and ugly illnesses) with some success. Taxing guns may make ownership go down and perhaps even feed back to production to reduce that. It seems like a reasonable approach and could spread.

It seems like we should step away from partisan politics where guns are concerned and decide to engage in moderation. We did that 50 years ago with cigarettes when the surgeon general told us that they caused cancer. We should do it with sugar as well, as our population is becoming fatter and more diabetic. It is never easy to give up that thing we think we love that is really bad for us, but we need to think, as a nation almost perpetually in mourning over some shooting incident or another, if it isn't just about time.

Wednesday, October 4, 2017

Physician Burnout and Suicide

Physician burnout and physician suicide has been getting more attention in the last several years. Suicide among physicians is horribly tragic, and maybe moreso because of several factors. Suicide is the quintessentially most preventable fatal event. In order to prevent suicide, the person killing him or herself needs only not do it. To anyone who knows the victim/perpetrator it seems that if only the right words had been spoken, the right sentiment expressed, comfort offered, their death would not have happened. Among the family and friends of a suicide, this is one of the agonies that is added to the pain of loss. Physicians have a huge number of close contacts, patients and coworkers, who have a pretty intimate connection with them, all of whom mourn their loss and many of whom question whether they might have had something to do with it. Beside the emotional impact of the loss is the very real fact that physicians are responsible for some part of the care of potentially thousands of people who are left stranded by their abrupt departure. There is the very sad fact that someone whose job it was to help people was unable to get the help they needed.

It is not clear that physicians commit suicide at a higher rate than people in other professions, according to a report by the CDC last summer, and although it is the number one cause of death among male medical residents per a study that was released this year, their suicide rate was lower than average for their age group. Although burnout is clearly increasing among physicians, I have not seen any data that shows that suicide is increasing.

I have been a witness to the kinds of stresses that lead to suicide in physician colleagues. So far, knock on wood, none of the doctors who work closely with me have committed suicide. I have, however, been around some pretty spectacular cases of burnout. According to a Medscape poll, 40-60% of physicians show signs of burnout. Surprisingly, the major problem they complained about was the excessive bureaucratic tasks that they had to do. It was not the stress of making life or death decisions but the grinding demands of the computer, the paperwork, satisfying insurance companies, convincing organizations that monitor quality that they were delivering it. Other frequently mentioned complaints included extended work hours and feeling like they were just a "cog in a wheel." My experience is that it takes more than a bad job to push a person over the edge, though. But life is pretty good at offering that little bit more. The breakdown of a marriage, a child with troubles, an illness can take a person who is competently holding on with her fingernails and plunge her into failure. Alcohol and drugs provide respite and destroy that last pretense of being able to do the work. The colleagues I've seen go through this usually step away from practice and may or may not return.

My worst times were early on in my career. During my first year in medical school, I comforted myself with the thought that if things got too bad I could just jump out of the tenth story window of my dorm. After awhile I replaced that with deciding that I would  just go live with my sister and cook for her. The first year was bad because there was just too much stuff to learn and if I stuffed my head full of it, as I needed to if I was going to pass my tests, I couldn't sleep. If I couldn't sleep I couldn't stuff more information into my head so I walked around gripped by fear of failing. Occasionally I was distracted from my misery by some of my really excellent teachers and was eventually saved by a prescription for sleeping pills. These I hoarded and doled out by the fragment so I wouldn't have to ask for more. A boyfriend and increasingly close friendships helped make the second year almost imperceptibly better. By the third year the opportunity to interact with real patients and be of use cured me. Training continued to be stressful, but there was always something rewarding that came back to me from grateful patients or collegial professors which gave me the joy I needed to make the process sustainable.

After completing my residency, I took some time off to find the right job. I got a house with the man who would eventually be my husband and a big yellow dog. The position I finally found was good, though demanding, and I enjoyed learning from other physicians at my work who had different skill sets than I did. I was able to keep up and felt I did a good job. Burnout threatened when my workload increased and I felt like I couldn't keep up. There was always more that I needed to do at work but home needed me too. Having a baby actually helped because the woman who we hired to help take care of her was wonderful and made me feel like home was well taken care of.

Six years ago I transitioned from a pretty sustainable to a very sustainable lifestyle, doing shift work as a hospitalist. My children have fledged and I no longer need to help them with their homework after work or worry about childcare if they get sick. I still do some outpatient medicine, but have not been sucked up into the complexity of documenting for merit based payment or pay for performance systems. I did go through the growing pains of adopting several computerized health records, both inpatient and outpatient, and have experienced first hand how that can make everything seem impossible.

I can see that in a clinic system where an employer was pushing the physician to see more patients in an hour and patients were pushing back to get what they need, administrative tasks could be a big part of burnout. The recipe, I think, for burning out is one cup of impossible and maybe conflicting demands and several tablespoons of feeling like something terrible will happen if you don't meet those demands. When the demands are from both home and work, things get pretty grim pretty fast. If the work is not rewarding, as it would tend not to be when you can't do it properly, then there is no joy to counteract the stress.

Medical offices and hospitals right now are in a time of transition, which makes things particularly bad. We are moving toward making computers do the work that humans find tedious, but the interaction of computers and people is still awkward. We end up doing lots of the work that the computers eventually will be able to do themselves, keeping track of nearly endless and very complex data, remembering schedules invented and tweaked by organizations charged with optimal care for chronic diseases. We are wrestling with computers instead of doing the human job of reading people and helping them solve their problems.

It is not entirely our jobs which lead us to the brink of suicide and beyond. We are humans with sadness and stories and connections which can be difficult or even crushing. But we can make the job part of this much easier. We need to allow computers to do what they do best and have doctors do doctoring. We need to figure out how to unhook a doctors monetary compensation from how many patients we see, so we can keep those patients healthy and out of our offices and hospitals where they belong. We need to not take on more than we can do well, even if that means saying "no" to the person who writes our paychecks.

Sunday, August 20, 2017

How a pocket sized ultrasound pays for itself--every week

I bought a pocket ultrasound in 2011, determined to learn how to perform and interpret ultrasound at the bedside and thus transform my internal medicine practice. I bought it new and it cost over $8000. That was a staggering amount of money to spend on something I knew very little about. In 2015 after having performed many thousand ultrasound exams with my little GE Vscan with the phased array transducer, I replaced it with the new model which had a dual transducer, with one side for deep structures and one for superficial structures, such as bones and blood vessels. It cost around $10,000. This was an even more staggering amount of money, but more of a sure thing. I knew that it made a difference and that the cost of the machine was a very small portion of the benefit that I would get from using it.

Since the time I bought the new machine, GE has come out with an even fancier machine that is just a wee bit faster and has internet connectivity and a touch screen. Because everyone needs the newest thing, the earlier models like I have are much more reasonable. Without even bargaining, the first machine I bought is available on Ebay for many thousands of dollars less than I paid. I am not trying to sell Vscans. In fact, Phillips has a very lightweight tablet model that gives even better pictures than mine and Sonosite has the iVIZ which also has gorgeous images. These machines are not yet inexpensive, but some day will be. There are bluetooth transducers which interface with tablets. There are very small Chinese machines that are quite inexpensive, but I haven't played with them and can't vouch for their quality.

I think of my Vscan as an $8000 machine. Now it's more like a $6000 machine per Ebay, but it still isn't a small expenditure. I like to believe that it's worth it. Since a day in the hospital in the US costs about $2500, when I avoid 3 hospital days by doing ultrasound I consider the machine paid for. Every time using it saves someone's life, I consider that it paid for itself several times over. In the small picture, I don't actually get that money, but in the big picture I do, since all healthcare dollars come out of the same pot eventually.

Here are the ways bedside ultrasound paid for itself this week:

1. A 45 year old man was admitted with alcoholic hepatitis on top of known cirrhosis. He starts to improve but his abdomen is painfully large and so he is sent by my colleague for a paracentesis, to have the fluid in his abdomen drained. They are able to remove a liter of fluid but a couple of days later he is feeling full again and wants the procedure repeated. I look at his abdomen with my bedside machine and am able to reassure him that there is very little fluid to drain and that his discomfort is caused by his huge liver which will gradually return to a more normal size if he stays off alcohol. One procedure and one hospital day saved.

2. A 90 year old woman whose small bowel obstruction has resolved is ready to go home. I notice that she is a little bit short of breath and I wonder if she has developed congestive heart failure. Her lung exam shows some crackles. I ultrasound her lungs and find that she has just a few "B lines" (indicative of wetness of the lung tissue) in the lower right lung, most consistent with the mild changes often present when a person has been at bedrest. She can go home. She is happy. One hospital day saved.

3. A 50 year old man is recovering from surgery for a perforated colon. He has developed abdominal distension and pain. The surgeon orders a CT scan with oral contrast. The patient is sitting up in bed with a bottle of contrast solution beside him. He is very unhappy. He can't imagine drinking the 500 ml of liquid and feels he might vomit it. I ultrasound his abdomen and find that his stomach is huge and fluid filled and his intestines are swollen and completely full of fluid, filling his abdominal cavity. With this information the surgeon, radiologist and I come to the consensus that having him drink the contrast medium will be useless since it will go nowhere, and what he really needs is a nasogastric tube to drain his stomach and small intestine. The patient is spared the bad things that might have occurred had we attempted to add more fluid to a tense water balloon and appropriate therapy is not delayed. Monetary value=hard to say.

4. 60 year old man is in the hospital after a hip fracture. He is on many pills for pain and for blood pressure which have been re-started after his hip surgery. I am called to the bedside because his blood pressure is very low and he won't respond. Bedside ultrasound shows that his heart, lungs and abdomen are all normal, with no evidence of a heart attack or a blood clot to the lung. His inferior vena cava, which brings blood to his heart from the lower part of his body is so small that it is invisible. He responds well to a liter of IV fluid and a little bit of oxygen and is sitting up eating dinner a couple of hours later. Ultrasound allowed me to rule out complications that would have required further testing or intensive care. In retrospect, he had very little money and no way to pay for most of his medication, so had not been taking all the pills on his list. The many sedatives and blood pressure pills hit him hard. Beside avoiding an intensive care unit transfer and complex testing, he was also able to be discharged the following day since he felt fine on fewer pills.

It's not just the money. (Though, in my experience, it does save money.) Knowing more about what's going on by way of bedside ultrasound allows for more appropriate and compassionate care. It's also much more gratifying to a doctor than guessing.

Thursday, August 17, 2017

The demise of the lecture--the rise of real education?

Today in the New England Journal of Medicine I read an editorial that discussed how lectures are being phased out in medical school education. I was, at first, a little bit appalled. Why would they eliminate an educational method that worked so well for me and my generation of doctors?

Or did it? I actually remember only a few things now from lectures, and all of those things don't support the idea that lectures were an effective way of teaching. I remember vividly how I would fall asleep and write progressively more poetic and less linear notes in my binder. How I would startle myself awake, causing heavy textbooks to fly in the air. I remember the time when the professor showed us the structure of vitamin B12 and I considered learning it, just for grins, and decided not to. I remember formulating questions for the lecturer that would display such minuscule understanding of the material that he or she would actually understand how deeply we students had been left in the dust. But I don't remember learning anything. I'm sure I did, at least eventually, when I highlighted and rewrote my lecture notes and read the material in the book. I'm not sure lectures were a good use of my time, or that of the eminent scientists and clinicians who were trying to teach us.

I do remember learning things in the laboratory. I remember learning about diptheria as we carefully sucked virulent Corynebacteria diphtheriae into glass pipets to examine it under the microscope. I remember using machines to understand sine waves and the concept of gain in order to learn how monitoring of vital signs could go wrong. I remember working with a group of 4 medical students to dissect a human body and how I worked with my professor-attending to reveal obscure diagnoses of real people. I particularly remember how a classmate and I decided to learn half the material in a certain class really well and teach it to the other person, creating a typed handout with jokes and cartoons and completely acing the essay exam on that subject.

What particularly bothered me about this idea of getting rid of lectures was the thought that students would have no structure to their learning, that they would just bop around aimlessly trying to absorb the enormity of medical science. Reading on, however, I realized that what is intended to replace the lecture are shorter and smaller doses of facts interspersed with questions and group work and cases that integrate the facts with problem solving. Medical students will still need to get up in the morning and come together in classes, but the classes will be different. The author mentions that students who hear an eloquently presented lecture may feel that they understand the material, but on further questioning realize that they have only a very superficial grasp. This is intuitively true and I know I have seen it, meaning that even the most clearly delivered lecture probably isn't very useful from a practical standpoint.

A few years ago I attended a talk about how to give a talk. In the talk the speaker said that most people remember only 1 (or is it 3?) things from a lecture. I also remember that he said to practice in front of a mirror which I tried but will never do. I don't remember what else he said, except that he thought Steve Jobs gave a great talk. He was definitely right about the number of things most people remember, though I don't quite remember what he said.

The conclusion of the article about saying goodbye to lectures was that they really are going away, at least in their long and fact filled monologing glory. Good teaching may involve a speaker and a large group of listeners, but will include shorter and more easily absorbed facts interspersed with questions to ascertain understanding.

New methods of learning are based not only on the fact that humans have limitations in their ability to absorb information, but also on the exponentially increasing amount of it as communication and technology co-evolve to deepen our potential understanding of the natural world. It is no longer practical to expect a person to keep an adequate body of knowledge to practice medicine in his or her brain. A couple of teachers of bedside ultrasound, Mike Mallin and Matt Dawson spoke about "just in time" rather than "just in case" learning at a meeting a few years ago, arguing that we remember and learn things better when we access the information at a time when it is relevant. They created a phone app called "1 minute ultrasound" which gives a person just the information they need to perform a bedside ultrasound exam right before they go into a patient's room. "Just in time" learning. I know that I would never have remembered the basic science behind Acute Intermittent Porphyria had I not had a patient suffering from it who needed me to mix up an ink-black orphan drug to abort her painful episode. In fact, the disease was so complex and obscure that I had sworn NOT to learn about it since I would likely never use the information in practice.

Not all learning can happen "just in time" since a certain knowledge base is necessary to filter the information a patient provides in order to be thinking in the right general area. Also some emergency conditions require immediate action, though I'm often surprised how easy it is to brush up on a condition by using my cell phone, even in dire situations. A fourth year medical student pulled out a Palm Pilot 15 years ago when a patient asked about a drug interaction. As I promised I would check a reference on it, she had the answer. I am eternally grateful for my first introduction to a peripheral brain that expanded my own. Now I have volumes of updated information on any condition known to man in my pocket.

I know that we will cling to the lecture for many years, in medicine and in other learning situations. Big changes happen slowly. As I partake of them I will appreciate the art and the effort that goes into their creation and sense that they are a noble tradition. I will try to learn more than 1 (or is it 3?) things from each one, but I won't beat myself up when I don't. As a tool for learning or teaching, though, I may be about ready to say "Goodbye."


Sunday, July 2, 2017

Agreement and division--the American Health Care Act and what we all want

It's been hard to be a concerned American citizen lately. We are facing huge problems which will become larger in our lifetimes, including the need to take care of our increasing global population and the medical complexity of taking care of people who are becoming older and sicker. There is global climate change, which is hard for all but the most stalwart of partisans to ignore. There is an increasing gap between rich and poor in our nation and in many others, which places the rich and powerful at odds with the much more numerous and therefore potentially powerful poor.

To help guide us through these challenges we have a government so deeply divided on democrat/republican party lines that it is mostly unable to do anything creative at all. And we all pay them lots of money to be dysfunctional.

I have been following the activities surrounding repealing and replacing the Affordable Care Act. The ACA (Obamacare) was passed without a single republican "yes" vote in the senate. The American Health Care Act (AHCA = Trumpcare), if it passes, will do so without a single democrat voting for it. It has been difficult to write because it has to please all republicans, including those who feel that healthcare should just take care of itself using the free market and who would happily get rid of any federal subsidies. There does not appear to have been any attempt to make the bill palatable to democrats or even relatively conservative healthcare organizations such as the AMA. The most recent iteration abolishes taxes on investment income which is effectively a tax cut for the rich, takes away all federal money from providers of abortions, even if the vast majority of what they do prevents abortions and so may de-fund Planned Parenthood. It offers block grants for Medicaid instead of paying a percentage of Medicaid costs. This leaves states to either pay more for the program or make cuts to services if medical prices go up faster than the consumer price index (which medical costs have done historically.) It reduces subsidies to pay for insurance for many people who are poor which means that many of them will stop paying for health insurance which they will be unable to afford.

The AHCA, as it was written, also would have provided some subsidies for insurance companies which have lost money under the ACA and many of which have either withdrawn from exchanges or increased their rates. In Idaho, I read in our local newspaper, insurance costs are set to increase by 22% this year, which will be very painful for many people. The insurance companies were hit hard since passage of the ACA, because a republican dominated congress did not appropriate the money promised to the insurance companies in case of shortfalls. People buying health insurance through the exchanges may already be priced out of paying for health insurance, even if nothing is done to "repeal and replace" the ACA. Not only will this leave more people uninsured but rising health insurance costs affect all businesses that are required to buy insurance for their workers, which will either impact their employees' paychecks or even cause the businesses to fail.

The ACA, our present health care system, is like a house whose roof is leaking, and has been leaking awhile. Instead of fixing the roof in the first place we are now wrangling about how to build a new and crappier house. If we don't either fix the roof (which is vanishingly unlikely in a republican held legislature) or build the new crappy house, we will all be shivering in the corners pretty soon.

But there has been a bright spot in my thoughts about the future. I have been reading Srdja Popovic's book Blueprint for Revolution. He was a member of the group Otpor! which was partly responsible for mobilizing the people of Bosnia to oust their dictator Slobodan Milosevic. He talks about some of the ways that people can work together to get big things done. The most important step is to find out what issues virtually everyone agrees about and to move on those. Also to maintain a sense of fun and positivity, because that is what feeds people and helps them stay active.

Our communication via the internet, with a new addiction among some of us to reading what we think is "the news" has been both good and bad. One thing that comes of it is that the economy of the internet, which is driven by ads which are equivalent to real money and resources, pushes conflict. There are natural conflicts, but increasingly we are pulled in by more petty conflicts. People who basically agree, share a political party and a vast number of values, enter twitter or facebook wars about smaller points and end up mortal enemies. This is exactly how you can get more clicks on your comment or your news story and not at all how you can unite to make good things happen.

There are many things that a majority of American's agree upon. We want to be paid fairly for our work. We want our children to grow up safe and responsible and useful. We want to breathe clean air and have healthy food to eat. We want adequate health care that doesn't stress us financially. We enjoy beauty. We want to end the divisiveness that creates inefficiency in our government so we can further our shared values.

It is likely that if there were leaders who stood up and insisted on ending divisiveness in government, they would have followers of all kinds who would come out in force. Democrats and republicans, churched and unchurched, black, white and other rainbow colors of  people would be willing to march in the streets or sit down to a picnic together.

In a congress that was not divided along party lines a healthcare bill could be designed that would serve most of our needs. Legislators who populate the fringe would have to convince others of the wisdom of their ideas, but they would not control outcomes as they do now. Bernie Sanders just sent a letter to me and his 50 million other best friends and suggested "Medicare for All" as an option. This will never pass in a divided congress, but might just gain traction if combined with cost saving ideas that would make it palatable to republicans.

In our present political environment I do not know what to do about the AHCA. The progressive organizations who contact me daily by email urge me to write letters and make calls to my congressmen to oppose it. But I don't know that we have any other options at this point than a bill that, if left unchanged, will have long term consequences of reducing health care to vulnerable populations. Left un-fixed, the ACA is going to have some of the same problems, with bloated but cash strapped insurance companies pricing many people out of the market. If the AHCA is terrible, maybe we will get more substantial improvements as people stand up together to insist that they get what they need. Two states (California and Nevada) have already begun the process of assuring their people adequate health care. We need more action like this.

Most of all we need to realize that we are all in this together and that we agree on many more things than we disagree on. The ways in which we disagree are important. Debate, change and consensus making is a valuable use of our energy, but right now we need to also pull together and gently but forcefully insist that our government do the same.

I recognize and respect people who say that Mr. Trump, our frighteningly incompetent president, should not be "normalized" by cooperation. I do not trust that the election which put him in that position represented the wishes of the American people. But deep divisions and lack of cooperation preceded his presidency and brought us to where we all are. It is time that we all, as citizens, begin to visualize what we all want rather than feel complacent in our resistance.

Tuesday, June 20, 2017

Should a type 2 diabetic monitor blood sugars? Maybe not!

Today in the JAMA (Journal of the American Medical Association) I read that a group out of the University of North Carolina had actually done a randomized study of whether non-insulin treated type 2 diabetics (usually the adult onset ones) achieved better control of their blood sugars if they did a finger stick test of their blood glucose daily. It turns out that they do not. Blood sugars were not improved in a group of patients who monitored their blood sugars once daily compared to patients who did not monitor them at all. Also combining the blood sugar testing with an automatic message from the machine telling them how to interpret that blood sugar did not improve blood sugar control.

Since 75% of patients with type 2 diabetes are estimated to check their blood sugar and there are over 29 million Americans with type 2 diabetes, and blood sugar monitoring is moderately expensive (though better than it used to be), not checking blood sugars could save billions of dollars a year. But that's not all. The energy used to focus on those numbers, by patients, doctors and nurses, could be focused on something that might actually matter, like increasing physical exercise or eating a more healthy diet...

To be absolutely clear, this information does not apply to all diabetics. Insulin dependent diabetics, who usually get their disease as children, and absolutely require insulin to survive, do need to check their sugars. For those patients it's vital to know the blood sugar so that an appropriate amount of insulin can be administered to keep sugars as close to normal as possible. Even type 2 diabetics who use insulin often need to know their blood sugar levels in order to adjust their insulin dosages. Some type 2 diabetics take medication and a regular dose of long acting insulin, and it would be interesting to know if they, too, could forego testing.

Checking blood sugars is not simple, though it is a procedure that most people learn pretty quickly. It involves pricking the finger with a lancet to draw a drop of blood, placing the blood on a paper or plastic strip which is then read by a little machine which displays a number. There are talking machines for patients who are blind, there are machines with fancy functions, expensive machines, cheap machines...You can buy a machine without a prescription at places like Walmart and even buy the test strips over the counter now. It is, however, just one more thing to fit into a busy day and the numbers can make a person feel like a failure if they are high. The monitors require a certain amount of maintenance and sometimes malfunction, leading a person to make unnecessary adjustments or phone calls to health care providers.

This study does have some caveats. Many of the patients in the group that did not test blood sugars had been testing their blood sugars already, so it is possible that they had already gotten valuable information from testing. The patients were told to check their blood sugars once daily. It could have been than testing more frequently would have given better information and been more effective. For instance, if a patient didn't know that their lunch of yogurt and a ham sandwich lead to a higher blood sugar in the evening than a lunch of soup and salad, he or she might not change their diet appropriately.

Despite these issues, this study does indicate that we can safely allow many of our type 2 diabetics to stop routine monitoring. Previous studies have alluded to this, and many physicians are already backing away from badgering patients with type 2 diabetes to check their blood sugars. Nevertheless is remains common and is a way that a patient might mis-allocate time away from something active and directly beneficial to their health. It is probably time to allow many of our patients to relegate that blood smeared glucose meter to the back of the bathroom cabinet.


Tuesday, May 16, 2017

Reducing my cardiovascular risks--the ongoing saga

About 5 months ago I embarked on an adventure in healthcare. My healthcare. I decided to take medicine to reduce my cardiovascular risk. I recognize that my cardiovascular risk is pretty low, and when I am much older I may wish for a nice clean cardiac death before I lose my faculties. Having found a plaque in my carotid artery while ultrasounding myself, I decided that perhaps I should enter the ranks of consumers who take drugs to reduce their blood pressure and cholesterol.

Astute readers made various comments, including that perhaps I should first try diet, weight loss, exercise and that I should be aware that someone of my description has a low likelihood of actually benefiting from drug treatment of these things. These were reasonable comments. It turns out that I don't need to lose weight, being at the bottom of the healthy range of body mass index, and that my exercise level is pretty optimal, my diet is as evidence based as I can make it, and although I have a low risk for vascular disease, the ultrasound says I have it anyway.

I made it my mission to find drugs that would lower my risk of stroke and heart attack without sacrificing my health and well being. This has been surprisingly tricky.

No side effects
If I am to take pills for decades on the small chance that they will keep me from having some vile health event, they need to cause me no trouble. That means they can't make me feel bad and they can't cost very much money. They should also be unlikely to kill me.

Lisinopril
I started with lisinopril, an inhibitor of the enzyme that converts angiotensin to its active form. It is an old drug and inexpensive. It can kill me by making my tongue swell up unpredictably, but that is very unlikely. In certain circumstances it can cause kidney failure, but it can also prevent kidney failure. It is usually quite effective in reducing blood pressure. My pharmacy charges just over $1 for a 1 month supply. I found that it wanted to get stuck going down my throat (it's not very slippery) and that at a low dose it didn't do much to lower my blood pressure.

Atorvastatin
Statin drugs reduce cholesterol and reduce vascular disease, though their effects in patients who have not had any cardiovascular events are minimal. Atorvastatin is pretty cheap, less than $10 a month through my pharmacy. It can definitely make my muscles weak and painful, but I haven't noticed that so far. If it does make me weaker, I may never be aware of that, just thinking that I am experiencing normal aging. Since I am hoping to buy vibrant health, that would be a nasty little irony. It almost never kills anyone, other than by causing a slight increase in the incidence of diabetes, which definitely does kill people. My physician told me I had to take it at night, which means that I forget to take it most of the time. The reason that a person should take a statin at night is because it works best during fasting states. But atorvastatin is a long acting statin and can be taken any time of day. Now I will start being more compliant, taking all of my pills at the same time, vaguely with breakfast. After my first month of taking it nearly every day, my cholesterol was lower than it had ever been, well within guidelines. Whether this is a relevant surrogate measure for any sort of health benefit, I'm not sure.


Chlorthalidone or Atenolol/Chlorthalidone
A recent meta-analysis showed that chlorthalidone, an old and less frequently used thiazide diuretic, may be more effective than its sister drug, hydrochlorothiazide (HCTZ), in preventing cardiovascular disease. Other studies have shown that it is more potent, milligram for milligram and more long lasting. Unfortunately it is also more expensive than HCTZ by a factor of more than 10. It is, however, cheap when combined with atenolol, a beta blocker. (Why it is more expensive than its newer relative and less expensive in combination with atenolol is another story that has to do with the dysfunctional economics of drug pricing.)  Thiazide diuretics can lower the potassium level and the sodium levels and by that mechanism can kill people, but this can be monitored and is rare in its most severe forms. Beta blockers have been associated with dangerously low heart rates in some people along with weight gain and depression, but this is not common. I tried the combination. I had to get up and pee more often at night but otherwise it was innocuous. It did not lower my blood pressure very much if at all.

Lisinopril/HCTZ
Lisinopril in combination with a thiazide diuretic such as HCTZ or chlorthalidone is much more effective than either drug alone. They make a generic combination pill and it is also very cheap, just about the same price as lisinopril alone. I got a prescription for 90 of these, and after having taken 2 found they controlled my blood pressure very nicely, were easy to swallow and made me itch and burn in my sun-exposed areas of skin. HCTZ is well known to do this. Chlorthalidone can too, since they are similar in structure, but it didn't have that effect on me. Know anyone who needs 88 lisinopril/HCTZ tablets?

Lisinopril/chlorthalidone
No drug manufacturer in the US makes a combination pill of these two, and I'm betting when they do it will be expensive. But I did, after all, try taking lisinopril plus a half of an atenolol/chlorthalidone pill which has caused no side effects other than the annoyance of the lisinopril pill taking its time to navigate my esophagus. Hooray! Maybe. It probably gives me a little tickle in my throat. This is classic for lisinopril and is very subtle indeed for me. I don't cough all the time, but find that as I fall asleep or am otherwise not occupied, I notice the need to cough or have a sip of water to clear the tickle. This is nearly a deal breaker, but I am willing to wait awhile and see if it persists. This combination works well for my blood pressure.

Aspirin
Why not? Aspirin reduces the tendency of platelets to clump and form clots, so it should reduce my risk of strokes. It will also increase my risk of significant bleeding. Aspirin is a non-steroidal anti-inflammatory drug, and even though low doses do not work to quell knee or back pain, they can cause ulcers or heartburn. I had heartburn as a wee medical student but haven't had it for years. As a new aspirin user I have it again. Nothing terrible, but not nothing.

So theoretically I am now on lisinopril, atenolol/chlorthalidone, atorvastatin and aspirin. They pretty cheap, around $10/month for everything. That still is $120 for a year and $1200 for 10 years and likely to go up in price with time. I am a little more miserable than I was on no drugs at all, and I am being bad about both compliance (taking the pills all the time) and followup. My chance of benefiting from these drugs is low. The pills are on probation.

It is important to ask, while contemplating a lifelong commitment to deliberately putting toxic chemicals into my body, if my data is sufficient. My blood pressure runs 140-160/90-94 untreated (though it is quite normal after 20 minutes of meditation.) We know that treating a population of people to bring their blood pressure down below those numbers reduces heart attacks and strokes, but do we know that my blood pressure, in the setting of otherwise good health, is harmful at all to me? I have a carotid plaque: it is not obstructing flow to any extent, but is impressively lumpy and looks like Mt. Fuji on one view. It is calcified, so it has been there awhile. It probably formed before I even had high blood pressure. Did it happen in the physical stress of childbirth? Was it formed in any of the stressful years when bad life events disturbed my otherwise charmed existence? Is it merely a signpost indicating a path not taken, or will it eventually be one of many? In a nutshell, am I just fine the way I am?

So far the experiment with pills has not been a big win. I have definitely gained, however, from the experience of being a patient, though a mighty privileged one. I have learned that side effects are real, even if they aren't on the package insert, and may be in categories like inconvenience, worry and always wondering if I have a side effect. I have learned that effective medication can be pretty inexpensive, but that the dollar cost belies the expense associated with the life disruption that taking pills can have. And that even cheap pills add up over time. I've learned that when effective medication doesn't have the desired effect, it is sometimes because the patient isn't taking the medication, but sometimes because a given pill just doesn't tweak a given person's physiology in a way that works. I've learned that even though I consider myself to be very tolerant and easy going when it comes to physical hardship, if I mentioned all of these concerns to a personal physician I would almost certainly sound like a whiner.




Monday, May 15, 2017

Bystander CPR--some interesting statistics

"Annie, Annie, are you OK?"

Many of us learned to resuscitate a person who has collapsed using Annie, the manikin based on a death mask of a young woman who had drowned in the Seine in Paris in the 19th century. Bystander cardiopulmonary resuscitation (CPR) has become increasingly accepted and expected as the years have passed, and we have even begun to make affordable machines to deliver a life-saving shock (defibrillation) to the heart of a person who has collapsed with an otherwise life threatening heart rhythm disturbance.

We lack, though, much good information about how useful the procedure is in saving lives and bringing people back to meaningful existence.

A recent study completed in Denmark looked at the outcomes of bystander performed CPR and defibrillation. Denmark has been quite aggressive in training and encouraging citizens to perform CPR when a person collapses and is found to have no pulse. They have also been scrupulous about keeping records of what happened in each of these cases. Records spanning 2001-2012 show that having bystander CPR helps a person to survive with their brain intact, more than just waiting for an emergency medical technician to arrive with the ambulance.

What is most interesting, though, is the overall outcome of cardiac arrest. In the period of study, 8.3% of patients on whom resuscitation was attempted survived for 30 days. Of these, 10.3% had brain damage or were admitted to nursing homes. As bystander CPR became more common, the percentage of patients surviving cardiac arrest rose, and was over 12% by 2012. Also, compared to no bystander CPR, those who received bystander CPR were much less likely to end up in a nursing home. The group of survivors with the best outcome were those who were treated by bystanders with an automatic defibrillator; only 2% of those survivors had brain damage. Of the patients who survived for 30 days, 9.7% died in the subsequent year, most often of heart disease.

So, to recap, slightly more than 1 in 10 Danes who collapse and receive cardiopulmonary resuscitation survive over 30 days. Of those who survive, about 1 in 10 will have brain damage sufficient to require nursing home care. Since Danes have healthcare statistics pretty similar to Americans, this study may represent us pretty well. Getting cardiopulmonary resuscitation as soon as possible, in most cases this means by a bystander, probably gets the blood flowing to the brain sooner and helps prevent brain damage in survivors. Having a defibrillator available and using it is even better.

It is a powerful thing, being able to bring someone back from death. If we choose to engage in it, we should stay skilled, start right away after a person collapses, be aware of defibrillators in the places we frequent and plan to use them, and understand our limitations. For those of us who don't want the to receive vigorous resuscitation with a significant risk of failure or brain damage, displaying this preference, possibly with a medical alert bracelet or necklace, may be wise.




Tuesday, May 9, 2017

Don't look hard for thyroid cancer--you will probably find it

Gilbert Welch has written an excellent commentary on the fresh-out-of-the-printer recommendations of the US Preventive Services Task Force (USPSTF) regarding screening for thyroid cancer. Dr. Welch, a professor at Dartmouth University, has spoken out about wasteful and harmful procedures done in the name of prevention. He is a compelling writer, has written several books aimed at people who are not doctors, and has captured the essence of the thyroid cancer screening controversy in this article, published in JAMA today.

Briefly, he applauds the recommendations of the USPSTF which state that there is no evidence that looking for thyroid cancer in people who have no concerning symptoms (symptoms such as a neck lump, difficulty swallowing or hoarseness) helps them. He looks at the population data on thyroid cancer, first evidence out of Finland that suggested that nearly everyone probably has a small thyroid cancer if you look hard enough, and evidence that discovering and treating these tumors does nothing to reduce the rate at which people die of thyroid cancer. Death from thyroid cancer has always been very rare, and thyroid cancers are pretty common.

He also discusses how the USPSTF can continue to develop recommendations which are based on evidence but often go against what is commonly done by physicians. The panel is made up of volunteers who are physicians in primary care and epidemiologists, medical professionals who study how disease occurs and can be controlled in populations. This limits conflicts of interest since none of these professionals stands to gain from promoting or discouraging given procedures. Apparently in November of 2016 legislation was introduced to put specialists and representatives from industry on the USPSTF. It did not pass, and should not be allowed to pass if it is introduced again. Screening for thyroid cancer results in many people being diagnosed with thyroid cancer which would never harm them if left untreated, but will result in hefty medical costs which will go to endocrine specialists, surgeons, pharmaceutical manufacturers and radiation providers. It is vital that task force members not be connected to fields which would gain or lose based on their recommendations..

Those of you who have been following this blog may recall the saga of my very own thyroid nodule. Much like many of my fellow humans who have been overdiagnosed with thyroid cancer, my thyroid nodule was discovered by an overzealous doctor. Actually me. I hadn't had a physical exam in awhile and thought maybe I better check myself out to see if there was anything amiss. I discovered a small lump in the right side of my neck. Being skilled in ultrasound, I headed down the very same garden path trod by the ranks of the overdiagnosed and had a scan (by me) of the nodule. It had characteristics that were benign and ones that were suspicious. I chose to follow it along for a year or more, but was alarmed when I heard that even benign appearing thyroid nodules sometimes harbored thyroid cancer. I was lucky at this point, however, when my thyroid biopsy (which hurt a lot and was very expensive) did not show cancer.

With the present guidelines, I would have spared myself multiple repeated ultrasound scans (all free in my case, because I did them myself) and the fear that persisted over the time that I followed the nodule as well as thousands of dollars and a very sore neck. Had thyroid cancer been discovered, and data suggest that it is probably there somewhere, I would have also had surgery, radiation and regular followup for recurrence, putting me at risk for complications and costing many tens of thousands of dollars, to say nothing of work lost, anxiety, pain and inconvenience. The new recommendations of the USPSTF will likely draw criticism. Those recommendations appear to me to be well considered and right on target.

Do read Dr. Welch's commentary. He is an excellent writer. Also be aware of the great resource we still have in the USPSTF which can say true things that might be unpopular with other powerful interests.


Thursday, May 4, 2017

How reduced regulation by the FDA will save money--except not

There is enthusiasm in politics about reducing regulation to stimulate creativity and economic growth. Maybe. But reduction in oversight of medication and medical devices by the Food and Drug Administration (FDA) will probably lead to a proliferation of expensive potions and gadgets that don't actually help.

This week, the New England Journal of Medicine published an article detailing the near miss associated with an injectable monoclonal antibody for Alzheimer's disease. (Spoiler alert: it doesn't work.)

Authors Chana Sacks, Jerry Avorn and Aaron Kesselheim detail the saga of Solanezumab, a drug that attacks the protein in the brain that is associated with Alzheimer's dementia. A monoclonal antibody is a molecule that binds to a specific target allowing the immune system to clear it from the body. Solanezumab binds to amyloid beta protein which is increased in the brains of patients with Alzheimer's disease. Although it may help clear amyloid protein from patients' brains, it did not help patients' brains to work better. It wasn't clear that the drug was worthless until all of the studies that the FDA required were completed. In fact, before the final, costly and rather time consuming trial, it looked like it might help patients with mild dementia. But it really doesn't help.

Because so many people have mild dementia and are desperate for a way to delay or reverse it, this could have been a very sought after drug. We don't know what it would have cost, but we can guess that it might have been similar to other monoclonal antibody drugs on the market, ranging from $14,000 to nearly $30,000 per year. There are several million people in the US who have mild dementia, so the cost to Medicare, private insurance companies and individual patients would have been in the many billions of dollars each year.

Drugs can be very good at changing blood tests or pathology slides without being good at all at changing patients' health.

I will digress a bit here, on the subject of expensive monoclonal antibody drugs that don't actually do much to help people. Evolocumab (Repatha) was approved by the FDA recently as an injectable drug to reduce cholesterol. This it does incredibly well. Read about it here. It has finally undergone testing to see if it really does any good by reducing cholesterol so dramatically and the results were hailed as a victory. The study enrolled patients with heart disease who were already on medication that had reduced their cholesterol. In this group, evolocumab actually does reduce the incidence of strokes, heart attacks, heart surgery or stents, hospitalizations for unstable angina and cardiovascular death, but only just a little bit. At the cost of over $14,000 per year for the injections, it saves only a few patients receiving the drug from these events at a cost of nearly $1 million per event avoided every year. If you only look at death or death from heart disease, there is no difference between patients who take the injections and ones who do not. Since the initial studies done for approval of this drug only looked at safety and the drug's ability to reduce cholesterol, it wasn't clear until after it was in clinical use that it didn't actually work that well for the outcomes we care about.

There are other drugs in other classes that looked like great ideas and weren't, and they either cost the taxpayer loads of money as we finally figured this out, or died in clinical trials. Drugs that increased the strength of the heart to treat heart failure often fell in this category, and, if they had been adopted in standard clinical practice, there would have been needless deaths in addition to needless costs. There are other drugs that appeared safe and were eventually taken off of the market when monitoring by the FDA showed significant side effects. The FDA monitors and approves (or doesn't) not only drugs, but also medical devices, food, cosmetics, veterinary products and machines which emit radiation. Its budget is $4.7 billion, of which not quite half is paid by the companies it monitors.

We should not ask the FDA to reduce its oversight of medication. What would be more helpful would be to increase funding for their efforts so they can do a better job and even complete an approval process more quickly when it's indicated. Perhaps an FDA with more funding and more teeth, not less, might have been able to be firmer with the makers of evolocumab, requiring it to show more efficacy before it was rolled out to physicians and patients eager to try something new to reduce the risk of heart attacks. The FDA's work on solenazumab, the Alzheimer's cure that wasn't, more than paid their cost to the taxpayer.

Sunday, April 2, 2017

Medicaid and the national debt--why should we shell out so much money for healthcare for the poor?

Medicaid, the program that provides funding for adults, seniors (along with Medicare), children and people who are blind or disabled who can't pay for their own healthcare, is expensive. It is painfully expensive. The program, along with CHIP (the Children's Health Insurance Program), marketplace subsidies and Medicare is responsible for 25% of the federal budget. Total Medicaid costs in 2016 were around $532 billion per the Kaiser Family Foundation. States fund up to half of the cost of Medicaid, and in my state, Idaho, our share of Medicaid and related payments makes up about 21% of the state budget.

Medicaid is a safety net that allows people who can't afford private insurance or to pay out of pocket to get healthcare. It pays for doctors' fees, preventive care services, hospital care, mental health care, the majority of women's costs for pregnancy and childbirth and costs for the impoverished elderly who are in nursing homes. It pays for emergency room visits. It pays the costs of care for people who are uninsured and become sick and their healthcare debt makes them so poor that they are then eligible for Medicaid. With small exceptions, all medical bills for those insured under the program are paid by Medicaid, with none of those nasty co-pays left over. It often pays less than other insurance companies for the same services so some providers will refuse to accept Medicaid insurance, but the full spectrum of care is available to patients including such things as organ transplants. Medicaid has different names in different states: Oregon Health Plan in Oregon, Badger Care in Wisconsin, MediCal in California for instance. It has been expanded in  32 states under the Affordable Care Act to cover people making up to 138% of the federal poverty line.

Presently the federal government pays a percentage of the medical bills of the Medicaid insured patients and the states pay the remainder, usually a smaller amount. Medicaid block grants, which have been proposed by Republican lawmakers, would still pay the majority of Medicaid costs, but would pay a fixed amount, rather than a percentage, and that amount would increase at a rate slower than the predicted increase in healthcare costs. Thus the federal government's share of the bill for Medicaid would gradually shrink. This proposed change is temporarily on hold due to snags in Republican's efforts to produce and pass a healthcare bill to replace the Affordable Care Act. I and many other people have shared opinions about block grants over the last month. The bottom line is that they would likely shift costs from federal to state governments without making a major impact on overall costs.

But the real question that arises, as we consider reducing payment for Medicaid, is why we should pay for it at all. That question underlies the question of how to fund it or whether to increase or decrease the resources we put into it. Why should those of us who are taxpayers, especially wealthy and therefore hefty taxpayers, put such a lot of money into a program that pays for the healthcare of people who, by their status as patients qualifying for Medicaid benefits, pay little or nothing in taxes?

This is an awkward and uncomfortable question to ask. My first response, as a person who believes in the inherent worth and dignity of every human, is possibly misguided. That answer, based on a kind heart alone, is that we pay for healthcare for the poorest and most vulnerable because it is the right thing to do and it would be terrible for people to die or suffer from treatable or preventable diseases because they don't have the money to pay for care.

But, according to The Economist, many of the other countries in the developed world came to take on the responsibility of universal healthcare because it was extremely inconvenient to have many of one's citizens sick, especially when they were necessary to staff a war somewhere. To take this further, the best argument (or at least the most robust one, from a political standpoint) for providing healthcare to the poor is that a healthy population makes for a more successful country. People who aren't disabled by chronic diseases or the sequelae of epidemics tend to be better workers, invent more things and require fewer subsidies.

But how can we tolerate, in all good conscience, the staggeringly large national debt that is necessary to fund a program like Medicaid? Our federal deficit last year was $572 billion, almost the same number as our spending on Medicaid. If we just cut Medicaid completely, we would be nearly deficit free. Aside from the fact that eliminating Medicaid won't even begin to be a possibility, and that it is a terrible idea for all sorts of reasons, it is financially stupid. Our debt, alarming as it may be, can be looked at as using borrowed resources to create a healthy and productive country. Paying interest on that debt is the cost of maintaining programs, such as Medicaid, that make us more productive. Debt is a good bargain if we get more in productivity than we pay out in interest.

The most important question, then, is not how to reduce the costs of Medicaid but how to get good value for our money. Medicaid, in order to give good value, needs help. It has excellent aspects. It provides healthcare for many children. That is clearly a good investment. Children, when healthy, grow up to do great things. It cares for poor families who have children, which is clearly a good investment, because healthy families are more likely to raise children who are healthy, creative and self sufficient. It pays for nursing home stays for the elderly after they can no longer afford to pay for themselves. Right now that is vitally important because families and friends who would be required to care for them at home can be freed up to do all of the things that they were intending to do, including jobs and education. Designing ways to allow the old and disabled to be at home rather than in institutions would be better, and that is a direction that Medicaid is trying to take. Caring for people with developmental disabilities or disabilities relating to injury or illness is important because this is specialized work, and not everybody, including their families, necessarily does it well. This is a valid role for Medicaid (though plagued, like much of healthcare, with preventable waste.)

Medicaid's real weakness is that it pays and keeps on paying for the diseases of self abuse and is not designed to make the necessary social impact to prevent the misery that leads to the problems of drug abuse, interpersonal violence, alcoholism and morbid obesity. The endless circle of getting sick or injured because of poor life choices in impossible situations, being patched back together at astoundingly high cost and then returning to the same situation to repeat the process is demoralizing for all involved. From an economic standpoint, it is also Medicaid money wasted. Solving this problem involves creating healthy communities. It needs to happen despite the fact that the people who need this help have close to no political clout. We must continue to treat these people when they come in sick and in need because it should not be the job of caregivers or payers to decide who is virtuous enough to receive care. But Medicaid does not function in a vacuum, and cannot give good value if it is not supported by other well designed social programs, designed to prevent their illnesses. Until we are able to focus reform efforts on the social problems that create some of our sickest and most hopeless patients, a substantial portion of public healthcare spending will not be a good investment.

Saturday, March 25, 2017

Bedside (Point of Care) Ultrasound of the Lung--So Good

Last week was a big week. Many patients. Lots of bedside ultrasound.

I've blogged on and on about my undying love for ultrasound at the bedside as a part of my physical exam. It keeps being powerful. It saves peoples' lives. It keeps me from making stupid mistakes. I am eternally grateful.

This week it helped with the usual things--hearts and bellies and bladders and lumps and bumps. I was able to tell patients what was going well and not so well, in real time, and show them pictures.

But ultrasound of the lung needs a little advertisement. Ultrasonographers and radiologists are terrific at imaging the internal organs, even those of tiny babies. Cardiologists and echocardiogram technicians are amazing in their ability to image the heart and describe its innermost workings. Although I leverage my ultrasound abilities by using my other exam and history taking skills, I do not have the extensive training in imaging that these people do. But in the US, only clinicians such as myself look at the lungs. Radiologists may look at the bases of the lungs for fluid, in order to more accurately sample or drain that fluid. But they don't look for pneumonia or pneumothorax (popped lung) or make predictions about the quality of pleural fluid based on what it looks like. So there is no question that the lung belongs to us, the non-radiologists.

This is a collection of 5 patients whose lung ultrasounds made an important difference in their care:

1. An ancient man, whose esophagus was completely non-functional, had continued to eat food despite the sneaking suspicion that it wasn't going down all the way. When he finally became too uncomfortable, his esophagus was packed with several meals and he was unable to swallow even his own saliva. The obstruction was relieved, but he then had a fever. Ultrasound of the lung showed the aspiration pneumonia that I suspected and I was able to decide on the appropriate treatment. He was so out of it after his procedure that he probably would not have been able to take a deep breath and the chest x-ray would probably have been inconclusive, and the ability to diagnose his condition with ultrasound meant that he did not need to be disturbed.

2. A woman arrived with a low oxygen level, kidney dysfunction and a bit of a wheeze. She had an elevated white blood cell count but no fever. Her ultrasound showed normal appearing kidneys and a left sided pneumonia. She responded well to antibiotics for community acquired pneumonia with increasing strength, no further need for oxygen and normalization of kidney function.

3. An octogenarian with endstage lung disease was short of breath a day after being started on bipap (bilateral positive airway pressure via mask). The nurses were unable to hear breath sounds in one of his lungs and were worried he might have a pneumothorax. A very quick check for lung sliding with my pocket ultrasound machine (the two layers of pleura moving against each other) proved to me, the nurse and the respiratory therapist that his problem was worsening airway obstruction rather than a pneumothorax. The patient was also happy with the attention. He was better by the next day.

4. A previously healthy young man came in with shortness of breath and a test positive for influenza. His ultrasound showed pretty significant pneumonia, due entirely to his influenza. It was clear that he needed to be hospitalized rather than sent home. His chest x-ray was equivocal. Ultrasound is definitely more sensitive for pneumonia than a plain chest radiograph, though determining the meaning of a wet area or consolidation depends on paying attention to other clinical information.

5. A patient hospitalized for another problem began to have increasing leg swelling and a slightly lower oxygen level. Ultrasound showed pleural fluid collections and he responded well to an increase in his medication for heart failure. Emergency decompensation averted. What I knew about the patient as well as the quality of the pleural fluid on ultrasound made it clear that this was related to his fluid status and not infection.

Radiologists do not look at the lung with ultrasound because normal lung looks like nothing, just gray fuzz with some horizontal stripes.This is because lung is filled with air like a slab of micro-bubble wrap and does not transmit sound well. They also have other imaging techniques, such as x-ray and CT scan which give them better static pictures. I'm sure they could develop advanced techniques for detecting pathology using ultrasound if they set their minds to it, but for now it belongs to us.