Why is American health care so expensive?

Seeing into the human heart--Valentine's Day and the GE V-scan pocket ultrasound

2012-02-13T22:56:00.000-08:00

Valentine's day is a silly holiday, sort of. Really unpalatable sugar hearts in colors not seen in nature with provocative non-sequiturs printed on them and children making 30 nearly identical tiny greeting cards for their class members and little stuffed puppy dogs with oversized plastic eyes holding satin heart pillows for sale in grocery stores and and and...yet... It is actually pretty wonderful that America celebrates a holiday in the middle of February, a very dreary month, that is dedicated to love and the human heart. Even if that holiday is hyped to a ridiculous level of excess by retail enterprises, it is still overall a good thing.

I am presently a fan of the human heart. After going to a short ultrasound course put on by the Department of Emergency Medicine at Harvard Medical School in November, I have been intrigued by the possibility of making ultrasound imaging a routine part of a physical exam, since it is harmless and uses no resources. When I got back from Harvard, I borrowed the small portable ultrasound machine in our hospital and ultrasounded everyone who would hold still when my working day was not too busy. The machine was inconveniently located in radiology and took awhile to get upstairs, but I still used it pretty frequently. I started out self conscious and inept and gradually began to be able to use the transducer in such a way that I could obtain images of the structures I was interested in, some or most of the time. In the first 3 weeks after the course I probably did 20 ultrasounds, with many disclaimers to the patients that I was just practicing and didn't really know what I was doing. They were nevertheless interested, and I found that the extra time I spent with them lead to more in depth sharing of stories and the images that I could get helped with diagnosis and treatment.

At the Harvard course there were lots of device sales people hawking their expensive machines, and one of them was a woman from General Electric who had a really little machine, small enough to go in a coat pocket, which gave pictures almost as good as the big machines. After dragging the portable but definitely not pocket size machine around our hospital for a couple of months, I decided that I needed to buy this pocket sized gizmo. I searched for deals online and found that there were many options, but that for what I wanted, small size and good picture, the GE machine was it. Siemens makes a nice slightly larger and slightly more expensive machine and a company out of Seattle makes a machine that uses an iPhone as its interface. This was intriguing, but I heard the pictures were just too small. I also found that farmers and veterinarians use ultrasounds and that theirs are much cheaper and would be perfect except that the transducer is shaped to go in an animal's rectum to image pregnancy and would not be what I would need for looking at people from the surface. The cost of the GE V-scan was nearly $9000, which only looked good in comparison to the larger models which are the size of a laptop and cost upwards of $50,000. I thought of how some rich hospital should maybe buy the pocket ultrasound for me, and realized that without having it and using it to know its utility, there would be no way to convince anyone to buy me one. I rationalized that I had not bought myself a new car since 1992 and didn't intend to anytime soon. I then shelled out the bucks. To buy this, I had to prove that I was a real physician and it was shipped to my work rather than home. I'm not sure who this was supposed to protect, but that's how it was.

Since buying my ultrasound I have begun to use it routinely, much as I would my stethoscope, but with greater confidence and it is incredibly helpful to determine whether a person has congestive heart failure, whether they are short of breath from a weak heart or from infection, whether they need more or less salt and water. I can also identify enlarged livers or spleens and can see if a bladder is full. With more training, which I will eagerly get in the next few months, it will become even more useful. There are so many decisions that I can make more confidently knowing what the insides of an individual look like, especially the heart.

The heart. The human heart is the most amazing thing. It is not hard to see why it has taken such an important place in art and literature. During medical school I looked at still pictures of the heart and dissected dead hearts and photos of x-rays of hearts and even the occasional ultrasound image. We learned how the blood flowed--from the body to the central veins, the inferior and superior vena cava, to the right atrium and then right ventricle, out to the lungs, then back, oxygenated, to the left atrium and ventricle, then out via the aorta to serve the body. But there is just nothing like looking at the heart in real time. Ultrasound allows you to tour the human heart, look at it from all sorts of angles, and though the picture is 2 dimensional, the myriad views I have allow me to perceive it in 3 dimensions.

The left side of the heart is the larger of the two sides and gets most of the attention. I am presently intrigued with the right side, though. The right side is not as strong a muscle as the left side, because the resistance in the blood vessels of the body is higher that the resistance in the lungs (except in severe pulmonary hypertension, which is a very bad disease.) But the right heart looks different from the left in a way that is utterly awe inspiring. The right heart dances. At least it does when it's healthy. The ventricle, which is more muscular than the atrium, pumps blood out, and as it does its contraction acts to pull blood into the right atrium from the great veins. They never told me that in medical school, but when I look at it, the process is absolutely clear. And when the atrium contracts to send blood into the ventricle, this thin walled structure appears to wink, as fast as an eye. It is totally cool to watch.

From the fact that I am able to get useful information from my little machine after very little training (though lots of practice) it is clear to me that this will become much more common and it will reduce the need for various blood tests which represent the state of health or disease of our innards much less accurately. Already emergency department residents are required to have a certain level of ultrasound competence to complete their programs. This will become standard in other specialties as the technology becomes cheaper and easier to use. I hope this new generation of physicians will search for the ways in which routine use of imaging can streamline diagnosis and spur useful conversations between doctors and patients. I hope they will also continue to be awed by the ability to see the inner workings of peoples' bodies.

Finding a mentor, and the joy of working with physicians who are not sheep

2012-02-07T22:06:00.000-08:00

Many physicians are thoughtful, intelligent, compassionate and creative, but the process of training for this job doesn't necessarily foster those qualities. And let me be clear, I have nothing against sheep, other than to have noticed that people who keep them don't seem to be particularly impressed with their problem solving abilities. I think that when we as physicians get particularly tired and overworked, we stop thinking for ourselves.

When I went to medical school at Johns Hopkins, there was a subset of clinical teachers who I thought of as the "grand old men and women of medicine." They were the people who understood their subject area with keen insight and who loved to teach. I felt privileged to be near them as they visited patients and explained their thought processes. Their ideas were fresh and they were passionate about them and they were definitely not sheep.

My recent locum tenens hospitalist job was really busy and there was a tendency to test and treat patients in ways that did not seem ideally suited to their individual needs. It was expeditious to do cardiac enzymes and then a nuclear stress test on everyone with chest pain who had any measurable risk of coronary artery disease, but I cringe to think of the cost and the radiation exposure associated with that approach. The American College of Physicians has made a recommendation that people with normal electrocardiograms who have chest pain can be risk stratified with a regular EKG stress test, without nuclear imaging without significant harm. The cost of a nuclear stress test is around $7000 whereas a regular stress test costs less than $400. Cardiologists and the hospital make more money on the nuclear tests, but the associated radiation will result in excess cancer risk. Invasive and higher risk procedures are compensated better than thinking and talking and this leads to increased use. The level of acceptance of routine use of procedures for testing and treatment is determined by the healthcare culture that is present in a hospital or community. I think the patients at the hospital where I worked got good care, but I wonder if their outcomes were any better than they would have been at an institution with more frugal use of resources.

The hospitalists in my new institution are responsible for taking care of most of the patients who are not critically ill in the hospital, but when these patients need ventilators or very frequent monitoring or vasoactive drips they are transferred to the intensive care unit where they are cared for by a physician who is assigned to just those patients, a critical care doctor. We hospitalists would occasionally go to the ICU to meet a new patient who had been adequately resuscitated to graduate to a regular medical floor, and in one of these visits I met the night shift intensivist who is also definitely not a sheep. He is an astute diagnostician and had great ideas about physiology that helped make sense of the very sickest patients. After a conversation that involved my present passion for bedside ultrasound to help manage medical patients, he offered to "show me stuff."

Physicians who are not sheep frequently do things in ways that make sheep uncomfortable. This ICU doc showed me his technique of putting in a central line in the subclavian vein using ultrasound guidance and a skin tunnel to prevent infection. Some physicians now use ultrasound to put in central lines, but rarely in the subclavian vein and I have never seen a tunneled central line placed by an intensivist. Now it is true that my exposure to this sort of thing has been limited for the last 20 years, but I'm pretty sure this is not only the right way to do it but also very uncommon. Skin tunnels prevent the bacteria that is always present on the outside of a human from getting into the blood stream, which is supposed to be pretty much devoid of bacteria. There are special central lines that are placed by surgeons that are tunneled and have special cuffs for use in lines that are expected to be left in place for a long time. The hardware and the placement process are really expensive. The procedure I saw involved the standard central line equipment and a bedside ultrasound machine and was beautiful. His procedure was relaxed and graceful and the patient was treated with respect. I was inspired.

Atul Gawande, the physician/writer for the New Yorker, wrote about being coached in doing surgery, and about how useful it was and how uncommon. Mentoring in medicine stops for most of us when we reach our final year of residency and from that time on, with the exception of short continuing medical education courses, we pretty much make things up as we go along. This year I have started to spend more time with doctors who know things that I don't know. The only way I could really do this is to pull away from the very full time nature of my primary care job and deliberately spend time listening to and watching people (doctors and technicians) who I respect. In the last few months I have seen many professionally done echocardiograms and ultrasounds, have watched my radiological colleagues do procedures and have seen a total hip replacement. Everything I watch opens up my horizons a little bit. I'm looking forward to more of this.

Adventures in Hospital Medicine

2012-02-01T22:06:00.000-08:00

I just started my first out of town doctoring job. I flew out for an orientation on Thursday and then drove back here for the week of work on Sunday. After Thursday's hospital visit my reaction was "what was I thinking when I said I would do this?" People go through a lot of trouble to end up in jobs where they are comfortable, well known and respected. This job, at least from the vantage point of last Thursday, was a very different thing. I would be responsible for somewhere between 12 and 20 patients who I knew nothing about in a hospital which has over 200 patient beds, 5 floors, 3 adjoining buildings, using two entirely new computer systems.

So what happened? I did sleep well the night before I started, which was great. They gave me 12 patients to start, and my beeper was mercifully quiet for the first 4 hours of my 12 hour shift. The patients were just people, like they are anywhere, which was reassuring, and they were grateful to have someone talk to them and listen to them and try to solve their problems. The computer systems were user friendly compared to lots of computer systems I've seen in medicine. The staff was harried but supportive. I brought my lunch. I got two admissions and discharged 3 patients and as far as I know I didn't make any heinous errors. The second day was a little harder but I was more comfortable, and today was ridiculous, with people needing to be seen at the same time in multiple areas of the hospital, some of them with logistical issues that were time sensitive, like discharges and procedures, and some of them with actual acute and life threatening illnesses needing intervention. Again, no obvious heinous errors, and everyone was quite understanding.

I'm starting to develop a routine that coordinates gathering all of the nearly infinite pieces of data that go into modern medical care (vital signs, lab tests, imaging results, nurse's observations, consultants and primary care docs' input, physical exams and patients' stories) and then seeing patients, admitting and discharging them and writing notes. Today was a little too free floating, I think, or maybe my patients were just really sick, but I ended up not getting out of there until an hour and a half after my shift was over. I shall make some subtle adjustments tomorrow and see how it goes.

I think this hospital, which is larger than the one I normally work in, has adjusted to the fact that the hospital docs, like me, are stretched thin, and even the patients are a bit more patient than I would be in their position. There are routine errors related to discontinuity of care, such as misdiagnoses and redundant tests and procedures. In general these have not seemed to have dire consequences, but they definitely could. There are systems in place to reduce this risk, but the frequent hand-offs of patients are difficult to do without information loss, Impossible, even. In my home hospital we do 24 hour shifts, going home at night, but always available within 20 minutes or less to come in if necessary. We usually do several days in a row, and know the patients pretty well by the time they are discharged. Our signouts are face to face, whereas the routine with my present job involves only a one or two paragraph computerized communication. With 12 hour shifts and a night and swing person covering all of the patients, face to face hand offs are not logistically possible.

I'm staying in a rather seedy hotel, but in a large room with a kitchen. I have very little time here, so the seediness doesn't much matter. I bought food at a grocery store and have been having comfort food meals like fresh raspberies, croissants with brie and nutella, ramen and hard boiled eggs and greasy chicken thighs. It's hard to improve on that! The locums company I work for will pay for my meals and lodgings so I could be eating out every night, but I shudder to think what a restaurant would charge for the fresh raspberries.

Some interesting new studies: Should you take aspirin to prevent heart attacks? Do statin medications cause diabetes? Does marijuana smoking cause lung disease?

2012-01-15T22:35:00.000-08:00

This week has been really interesting in the medical journals. Although I often question the relevance of population based medical research to guide treatment of individuals, large trials are excellent for helping us question widely held beliefs. Since doctors are often unreasonably convinced that they are right, studies that make us question ourselves are valuable.

Last year when reviewing recommendations of the US Preventive Services Task Force and looking at the studies on which these recommendations were based, I began to recommend regular use of aspirin for men over the age of 45 and women over the age of 55 to prevent heart attacks. This month an article came out in the Archives of Internal Medicine that showed that for patients without heart disease, there was no decrease in mortality with regular aspirin use and that the reduction in risk of heart attack and stroke is really quite small. Risk of bleeding related to taking even a baby aspirin is significant. This only leads me back to my previous position on the subject, which was that each individual should look at his or her risk for heart attack and stroke and weigh their risk associated with aspirin use and then decide if using it will make sense. The USPSTF had labeled aspirin use as a level A recommendations, suggesting that there was good medical evidence that it helped. They will probably change that, but usually those changes take awhile.

Use of statins for primary prevention of heart disease (that is prevention of heart attack or angina in patients who are not already known to have coronary artery disease) has been something I have hesitated to recommend. Statins, such as lipitor, have such powerful effects on so many systems that using them in patients who are otherwise healthy worries me. Cardiologist seem to be positively enamored of statins, and it seems that very little time passes between studies that show yet another benefit of statin therapy. As a primary care physician I saw many patients with side effects of statins, including muscle pains and stomach problems, many of which were not recognized as side effects until the medication was stopped. It just can't be good to take something that makes you feel miserable, even if that something doesn't kill you or cause organ failure. Many of my patients voted with their feet on the statin issue and just quit taking the medicine even after I had prescribed it and made a good case for using it. Statin safety was addressed in an article, again in the Archives of Internal Medicine this month that showed that in the Womens' Health Initiative patients on statins had about a 1.5 times average risk of developing diabetes. This was corrected for such issues as weight and other known risk factors. I can imagine that such a finding might still be just an association, since doctors might have put patients on statins due to perception of their risk for diabetes since diabetes often goes hand in had with elevated cholesterol levels. Still, I harbor ongoing suspicion of statin drugs since their manufacturers have made such an obscene amount of money on them which in turn fuels more advertising and feeds back to influence both clinicians and researchers. It will be interesting to see how this piece of data pans out since diabetes is hardly an acceptable medication side effect.

Finally, in the Journal of the AMA (JAMA) an article addressed the lung risks of long term marijuana smoking. An Article in the Archives of Internal Medicine in 2007 reported that marijuana dilated the small airways, which would tend to be a good thing, but was only able to say that long term smokers of marijuana often had a productive cough. In this article, pulmonary function testing was done regularly in a group of over 5000 patients who were being followed to look at risk of heart disease. These patients had periodic testing of lung function and, on average, low frequency but long term use of marijuana was not associated with lung disease and even frequent marijuana use was not clearly bad for the lungs. Marijuana smokers did have an increase in lung capacity that was theorized to be due to the fact that they learned how to take deeper breaths. I have certainly seen patients who have lung disease that looks much like that of my tobacco smokers even though they only use marijuana, and studies like this do not prove that marijuana is safe for everyone's lungs. Still, marijuana use is by no means equivalent to cigarette use in terms of respiratory complications. I suspect we will never see a study that looks at effects of smoking the amount of marijuana equivalent to a pack of cigarettes a day. Other complications of that level of use would probably eclipse breathing issues.

Good news about health care costs!

2012-01-14T14:07:00.000-08:00

Happy New Year! According to Health Affairs, a journal of health economics, the rise in health care spending in the US is flat, and spending on physician's services rose at an all time low number of 1.8%. The interpretation of this information is that health care, even though it is considered a necessity, has been impacted by the weak economy. That is certainly a factor, but it is interesting to see that health care spending can go down without the quality of care looking catastrophically worse In fact it looks like there are many areas of improved care in the last two years. My guess is that spending came down because there is enough fat (and there is still more fat) that can be cut just by physicians and consumers being aware of what is of value in medicine. We are probably also seeing effects of preparing for and responding to health care reform in a way that has reduced waste.

So happy New Year! We have started the year with health care costs that have risen only as fast as the GDP. We can do better, yes, but it is clear that better is the direction in which we are moving.

Is Pradaxa (dabigatran) dangerous? Comparing Pradaxa, Xarelto and warfarin

2012-01-14T13:33:00.000-08:00

Just today while poking through studies recently released, I came upon an article that added to my growing discomfort with using Pradaxa, an anticoagulant ("blood thinner") that is now being widely used as an alternative for warfarin (coumadin is the brand name) for people with atrial fibrillation in order to reduce their risk for stroke.

Atrial fibrillation is a condition in which the atrium (entry chamber) of the heart wiggles rather than beats, and is caused by high blood pressure, valve problems, alcohol abuse and a number of other factors. The wiggling rather than beating atrium can build up blood clots which can migrate into arteries all over the body, but most devastatingly in the brain to cause strokes. Taking an anticoagulant reduces this risk. But blood has a very good reason for clotting, and when it is inhibited from clotting, a person can bleed, sometimes catastrophically, from an injury or an ulcer or a week area in the tissues of the body. Like the use of any drug, anticoagulant use involves considering whether risks are less than expected benefits. Warfarin, our old standard drug, required that we monitor the level of anticoagulation with a blood test about every month. This was annoying and resource consuming, but had the effect of keeping us in contact with our patients and of making them realize, monthly, that there was risk associated with taking the drug. It was not uncommon for the level to drop too low to be protective, or to rise to the point that serious bleeding could occur. Still, most patients did fine. The drug became generic a few years ago so its cost was not too significant, and insurance covered the blood tests and followup.

Pradaxa, on the other hand, requires no monitoring. It is dosed twice daily rather than once, as for warfarin, but it is great to not have to worry about monthly visits. Warfarin blocked the action of vitamin K, so could be reversed by eating foods with lots of vitamin K, so patients had to be careful with their diets. Pradaxa has no such restrictions. Because Warfarin blocked vitamin K as its main mechanism of action, giving high doses of vitamin K was pretty effective in stopping bleeding if a person was injured or needed surgery, and if we needed to reverse it even more quickly we could use blood plasma. In the case of Pradaxa, though, there is no known agent that reverses its effects, though its effects do fade in about 24 hours. Unlike warfarin which takes days to become effective, pradaxa works in less than an hour, which in some situations might be life saving.

I was a great fan of Pradaxa when it first came out because my patients really did hate to get regular blood tests with warfarin and sometimes their doses were very difficult to stabilize. I saw many bleeding complications over the years that I practiced with warfarin, and occasionally strokes when the dose was too low. I woke up to problems with Pradaxa when I went to an Advanced Trauma Life Support course and found that the surgeons who dealt with patients who are injured were very opposed to anticoagulants, especially ones that couldn't be reversed. Patients who had trauma to their heads or abdomens and were on such drugs would bleed and die and the surgeon would have to sit by and watch. The surgeons asked why internists like myself would push so strongly to get patients to take these drugs to reduce risk of stroke, when the patient might just as easily die of bleeding should they fall or be in a car accident.

The article that just came out was in the Archives of Internal Medicine this month and showed that patients who took Pradaxa were 1.33 times as likely as patients who took no anticoagulants, aspirin or warfarin to had heart attacks or near heart attacks. I have no real idea why this would be, but the study was large and performed at several centers, so apparently something about this drug may make microclots in the coronary arteries occur or make platelets more sticky. In any case, it sure makes me think twice about using it.

Just very recently another drug like Pradaxa was released for use, and it may be better. The brand name is Xarelto, generic name Rivaraxaban. This drug is dosed once daily and can be reversed with a blood product called prothrombin complex. Its official indications are broader than Pradaxa. It can be used both for atrial fibrillation and preventing blood clots in the legs of patients who have had hip or knee replacements. It's likely that both Pradaxa and Xarelto are good for any clotting condition, but the FDA is slow to expand its recommendations due to the fact that blood clotting conditions are very risky, and there are other drugs that have long histories of effectiveness.

The cost of these new anticoagulants is really steep. Drugstore.com quotes a price of $245 for a month's supply of Pradaxa, and looking at sources online for Xarelto, costs for that will be really similar. Warfarin only costs about 15 dollars a month, but monitoring and complications bring the cost up significantly in the big picture. Both of the new drugs are less likely to cause fatal bleeding than warfarin.

So the answer to the question "is Pradaxa dangerous?" is "of course!" which also is true of Xarelto and warfarin.

Christian Science, faith healing and mind-body medicine with mention of the work of Elisabeth Fischer Targ MD

2012-01-04T01:21:00.000-08:00

Just this last week I saw a couple of ancient people who were at the end of their lives, had been very healthy up until recently and had received close to no medical care for nearly 9 decades. One of them was a devout Christian Scientist and the other was a Seventh Day Adventist. Christian Science began in 1871 based on the teachings of Mary Baker Eddy, and follows her teachings as laid out in her blockbuster bestselling book Science and Health with Key to the Scriptures which has been translated into just about every known written language and outlines the philosophy and practice of healing based on Christian faith. Seventh Day Adventists also have pretty strict health prescriptions and many of them eat a plant based diet, avoiding animal products, especially meat. I have had other Christian Science patients in the past, of great age, and am very curious about what draws them to it and how they weave it into their very healthy lives.

Mary Baker Eddy was a "sickly child" who heard voices and was known as someone who could heal sick animals. She remained sick for much of her adult life, even giving up care of her only son due to illness. She believed (and this is based on a pretty cursory look at her book, so take it with a grain of salt) that God and the spirit, love and truth and good, were all the real things of existence, and material things, including the body and matter in general, were false and mostly unimportant. Regarding healing she wrote "When the sick are made to realize the lie of personal sense, the body is healed." She described her religion as "primitive Christianity" and the churches she established were very popular and remain so, to some extent. One of the publications that began with the movement, the Christian Science Monitor, is still very active and an excellent source of non-partisan news.

I am neither a devout Christian nor an integrative medicine specialist or mind-body practitioner, yet I have had a longstanding interest in the power of meditation and focused thought or visualization to heal. Even at Harvard, that bastion of evidence based medicine, we see practitioners looking to find the science behind the success of various relaxations techniques and spiritual practices in curing illness and promoting wellness. A rather funny animal model of meditation (which I heard about at the Mind-body medicine course I just attended last month at Harvard) is allowing rats to shred pieces of compressed fiber to make nests. The happy shredders heal up experimentally inflicted burns much faster than their bored and idle litter mates.

I think that Mary Baker Eddy must have been sick with one of the diseases that is primarily characterized by pain and fatigue, like fibromyalgia, migraine headaches or chronic fatigue syndrome, since she died in her late 80s despite years of being ill in a time when medical care was at best ineffective and at worst toxic. Even now, though we have potions and pills galore for these conditions, most of them work poorly, with high costs and sometimes devastating side effects. I suspect that faith healing was a truly excellent approach for what she had, though it might not have been so effective had she suffered from tuberculosis or vitamin B12 deficiency.

What I end up with, after looking at the lives of healthy very old Christian Scientists, is a respect for their particular path. Much of what we, as physicians, hand out for diseases will someday be found to be at least as bad as blood letting, which does in fact work pretty well for both acute congestive heart failure and hemochromatosis. In a couple of decades we will cringe as we think of the patients who we treated with chemotherapy drugs for cancer who died of side effects with no significant beneficial effects on their tumors. I have seen a few tragic results of using faith healing to treat cancers, but I have also seen people who were diagnosed with relatively small tumors, treated with chemotherapy agents that made them feel terrible and died anyway. It seems clear that there are some people and some diseases that probably respond dramatically to faith healing and some that respond dramatically to the right chemotherapy drug.

My best friend in college, Elisabeth Targ, graduated from Stanford and became a psychiatrist who had a special interest in remote healing by non-denominational prayer. She attempted to rigorously test the effect of distant prayer on patients with AIDS and saw a significant improvement in their outcomes. The study was later questioned, but she was pretty impressed with the results when I talked to her before her death. She died of a very nasty brain tumor in 2002 despite prayer and psychic healing attempts from her very wide range of friends. The problem was, I think, that she just had a really bad disease that neither surgery, radiation, chemotherapy nor as yet undescribed psychic processes could cure. Watching her struggle with the side effects of her expensive chemotherapy drugs I would say that the psychic part of the healing was not nearly so nasty. Kind of nice, actually.

I think psychic healing and faith healing probably have an effect that is mediated by some of the same processes that are involved in the less far-out practices that are part of mind-body medicine. Meditation and guided imagery will be more easily accepted by the medical field because we come closer to understanding them and can more easily test them. The science involved in this will continue to be really difficult to do well, because you can't have a control group "pretend" to meditate, since even pretend meditation is meditation. Practices that can be taught and learned and repeated without medical supervision will be attractive for payers and this will partially counter the medical profession's reticence to use techniques that they feel are unscientific. Already the teachings of John Kabat-Zinn have been codified into a curriculum called "Mindfulness Based Stress Reduction" which has been spectacularly effective in treating conditions such as anxiety, chronic pain and insomnia. We will continue to learn what these sorts of things are good for, and perhaps we will move ever so slightly away from the modern approach of a pill for every problem.

How does Canada do it?

2011-12-29T23:24:00.000-08:00

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

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

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

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

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

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

Being a hospitalist and watching our hospital get digital

2011-12-29T22:53:00.000-08:00

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

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

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

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

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

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

Blog maintenance issues

2011-12-13T21:28:00.000-08:00

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

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

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

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

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

2011-12-12T18:49:00.000-08:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2011-12-07T20:35:00.000-08:00

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

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

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

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

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

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

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

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

2011-12-05T20:33:00.000-08:00

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

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

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

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

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

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

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

how to become a hospitalist part 1

2011-11-19T21:46:00.000-08:00

The field of "hospital medicine" has become increasingly popular in the last 10 years, especially for internal medicine physicians. When a person finishes medical school and enters residency, there are nearly boundless possibilities. Residency choices can include specialties such as radiology, surgery, dermatology, emergency medicine, neurology, psychiatry, family practice, pediatrics, obstetrics and gynecology, pathology and lab medicine and even internal medicine. I'm sure I'm missing something. If a person chooses internal medicine, she can still choose to become a cardiologist, rheumatologist, endocrinologist, oncologist or...again I'm sure I'm missing something. But after 4 years of medical school and then 3 years of internal medicine residency, which is a job, but with almost no time off and very little pay, some people are ready to start doctoring. I wanted to be able to be useful anywhere and be able to use the knowledge I'd spent so much time picking up in medical school to its fullest, and felt that specializing in one organ of the body would be a waste. That is why I am a general internist rather than a specialist. But internal medicine residency was full of taking care of enormously sick patients in the hospital, with small amounts of supervised clinic time, and when I first finished, I was really good at hospital medicine and pretty clueless about taking care of the many issues that come up in primary care. This is also true of internal medicine residents finishing up today. These doctors now have the choice of continuing to work just in the hospital, a choice that I didn't have. It is attractive. The schedule for a hospital physician is pretty cushy compared to a resident's schedule, and the pay is excellent. A standard hospitalist schedule is 7 days on, 12 hours a day, then 7 days off. What's not to like?

After quitting my primary care internal medicine practice, I have, by default, become a hospitalist. It is possible to do hospital medicine pretty much anywhere and still have time at home. Committing for the long term is not strictly necessary since most patients come in to the hospital, are discharged, and don't come back for a long time, unlike primary care where the relationship with a single physician is key to good care. I will certainly not do it forever, but I'm doing it now. I am presently helping to cover the shifts at my local hospital which is only 25 beds, so quite small. The standard schedule for tiny hospitals which have hospitalists is 24 hours shifts, but typically seeing no more than 12 patients a day, and sleeping at home most of the time. Our hospital is just now developing this program, which will allow the primary care doctors to not come in to admit patients on their off hours if they don't want to, and will give sick patients without a doctor someone who is pleased to take care of them.

There are many companies that just do the job of providing doctor manpower and organization for a hospital that needs hospitalists. These companies are kind of like temp agencies, making sure that the job is done to certain specifications and taking on the responsibility for coverage. I have recently signed up with one of these companies to provide services in a community about 6 hours drive away from where I live.

The company first has to credential me, and the hospital needs to credential me as well. This means I have to submit all of my vital statistics, including history of malpractice suits, even if frivolous, licensing information, straight from any licensing board that has licensed me, and a complete education and job history with verification from all of those places, plus letters of reference and yet more stuff. After credentialing, I need to complete an online training course in how this company does things. One of the primary focuses of the online training is making sure that I document (write, type, dictate) notes sufficient to avoid losing a malpractice case should I be unlucky enough to be called in one, and be paid at the highest ethical rate for anything I do.

I have been dutifully watching the required videos, and have been feeling like maybe this is the wrong job for me. Perhaps I should go to cooking school or start selling real estate or better yet go overseas to treat the really truly sick in a situation in which what I do has more to do with helping people and less to do with satisfying payers and covering my vulnerable rump. I love taking care of people, learning what their issues are, using my experience to help them navigate their way toward better health. In order to document as this company requires, I actually need to change what I do to fit a framework that revolves around billing.

Each encounter I have with a patient in the hospital must be billed in order for the hospital to be paid for what I do. In the notes for these encounters I need to document various elements of the history of present illness, the family, past medical, personal and social histories, specific elements of a physical exam, even if I don't consider them relevant, a systems review, make notes of all of the data that I review and in some situations document start and stop times. After awhile this will become natural to me, and take up less of my brain, but when it becomes natural, the patient encounter will be a different thing than it should be. It will have elements of a checklist and will not truly be about hearing my patients' stories and collaborating on a solution to their problems.

I do think this whole bizarrely complex routine will someday be obsolete, since it seems clear that medical care will move in the direction of being paid for results, that is making people well, rather than by the individual nit that is picked. Still, in the meantime I am feeling like my brain is being filled with drivel.

It appears that all of the good hospitalist companies do training similar to the one that has signed me on. Even though I don't like learning the intricacies of evaluation and management coding, it is the system we are presently using, and standardizing the way we interact with that system is not entirely a bad thing. It would be disappointing to learn that when I worked very hard taking care of a patient my hospital was paid as if I had done very little, simply because I had failed to mention that I had asked about new rashes or ear discharge or that I had personally looked at the chest x-ray.

The primary inventor of the complex billing schemes is Medicare, though many other insurance agencies follow the same guidelines. If I had my way, physicians and payers would sit down to produce a payment system that wasted minimal amounts of doctor and biller time on producing and reviewing documentation, focusing on making it serve the purpose of communicating important information among caregivers. Payment would be based on achieving goals derived through communication between the patient and or family and the care providers.

Bedside ultrasound--what a great way to improve medical care and potentially reduce costs

2011-11-18T20:12:00.000-08:00

I just completed a 2 day course in "point of care ultrasound" at Harvard Medical School. It was great. I am completely sold, a convert, a true believer.

Ultrasound is by no means a new technology. Bats use it. Bugs use it. Whales use it. A very high frequency sound wave is produced and when it hits an object it bounces back and is sensed by the creature that produced it. Submarines have used it since the first world war to locate objects, since other detection methods based on light were not useful. Doctors have used rudimentary forms of ultrasound since the 1940s to detect abnormalities in the body. In the last 30 years the machines used in ultrasound imaging have become smaller and more accurate, and the number of conditions that can be detected by ultrasound has increased vastly.

Medical imaging studies of all kinds have become better since I emerged from medical school, and the pictures of the body that they produce are beautiful. We have x-rays, an old technology, which look at the body by projecting radiation produced by electrons through flesh and detecting the emerging rays on the other side, initially being recorded on a kind of photographic film, and now more often by a silicon detection screen which converts the image into a digital file. X-rays impart ionizing energy to tissue and can cause healthy cells to develop DNA abnormalities which can turn them into cancer cells. CT scans use x-rays in larger numbers to produce more accurate images which a computer can use to create images that look like slices through the body. CT scans impart even more radiation to tissue than standard x-rays. They are also very expensive (at our hospital a CT scan can be billed at two to three thousand dollars.) In order to get more accurate pictures, a contrast material is often injected into a vein, which can cause fatal allergies and kidney failure. MRI scanning produces even prettier pictures, using the fact that powerful magnets can tweak protons (present in water) in such a way that they produce a signal which can be recorded digitally. MRI scans are not particularly dangerous, except that contrast material used for MRI can cause a horrible scarring condition of the skin in patients with kidney problems, and they are even more expensive than CT scans. All of these imaging procedures have probably saved countless lives while contributing to the development of iatrogenic disease and billions of dollars of health care related economic mischief.

Ultrasound imaging is very different than x-ray, CT or MRI scans. Safety is one of the greatest differences. Sound waves impart very little energy to tissue at the wavelengths and amplitudes used in medical machines. Although ultrasound can be used to clean your jewelry or your teeth, imaging ultrasound is much more gentle and does no appreciable harm.

Cost is another issue: ultrasound machines, unless treated roughly, are durable and can take many pictures without using resources beyond the initial cost of the machine.

Immediacy is the difference that has impressed me most. If I have a patient in my office who I suspect has something wrong inside their body, somewhere I can't see or feel adequately (and the body has lots of those places) I often recommend that they have some sort of imaging test. If it is an x-ray or a CT or an MRI, I order that test, send the patient to the radiology suite where the technician takes the pictures after administering the contrast material if that is required. Those pictures go to the radiologist, a physician who I know but usually don't actually see very often, who interprets what I think is wrong with the patient from a brief sentence I write on my order, looks at the picture, dictates an interpretation (or sometimes calls me, but not often) and I later read that interpretation. Sometimes I look at the picture too, but I am not as good at looking at those pictures as the radiologist, so often I don't. Traditionally, I only order an ultrasound to look for specific things that ultrasounds are very good at seeing: gallstones, blood clots in the legs, function of the heart or blockage of the kidneys. If I do, the technician performs the ultrasound and the radiologist then reads the moving picture of the ultrasound images after they are performed, because ultrasound is a very dynamic procedure, looking at the body's inner workings in real time and from many different angles, since every body is a little different. Still shots from an ultrasound are blurry and hard to read like a glimpse out of the window of a fast moving car. I rarely look at ultrasound images, because only the still shots are available to me and they are of limited use.

Enter "point of care" ultrasound, that is to say ultrasound performed by the examining physician when the patient is seen. When a person gets an ultrasound, a smooth plastic transducer, shaped a bit like the handle of a paintbrush, liberally coated with ultrasound gel is applied to the skin and images appear on a screen. If I am doing the ultrasound, I slide the transducer around, looking at the structures underneath the skin and adjusting my angles and the pictures on the screen until I have seen all that I need to see. If I see something interesting, I can look at it from another angle, can look at structures near it and generally investigate until I am satisfied. There is no sending the patient to a technician, no radiologist being unsure of exactly what I am interested in, no delay. The examination is simply an extension of my history and physical exam. Nice for the patient, because I can tell them more, nice for me because looking inside the human body is unimaginably cool. In the setting of an emergency room, where belly pain could be gas or something life threatening, ultrasound can make a huge difference in survival. Right now, many people with problems that are trivial get CT scans of everything, just to make sure. Costs are huge and radiation exposure considerable. Routine use of ultrasound by the physician at the bedside could be game changing.

There are drawbacks. Ultrasound can't see everything. There are lung conditions that can be identified, but many that can't be. Certain tumors are too small to be seen, certain other conditions just don't register on ultrasound. MDs who aren't radiologists may miss subtle abnormalities, and if they don't recognize their limits, could reassure a patient in error. Patients may assume that when a doctor has a look with an ultrasound, they will find everything that is wrong inside. Much like the standard history and physical, bedside ultrasound is limited. Doctors worry that if they are not great at ultrasound, they will be sued by patients who discover that something was missed. Still, after the experience that I have had (combined with medical knowledge and 25 years of looking at images) I think that I could help people considerably more with an exam that included ultrasound. And it doesn't really take that long, which is pretty amazing.

Here is an example of how bedside ultrasound might change my practice:

Scenario 1--appointment without ultrasound. A 35 year old woman comes in and tells me that she has been really fatigued lately and has had some belly pain. I ask her the usual questions, do a physical exam which is normal and decide that I need some blood tests and see her back in a week to discuss them. We talk about stress and irritable bowel syndrome and getting more fiber and more exercise.

Scenario 2--appointment with ultrasound. Same patient, same issues. I do a quick ultrasound. I am able to look at her liver, spleen, kidneys, and see nothing of concern. I quickly check her heart, and it is pumping normally, with no obvious problems of the valves or muscle. I then take a quick peak at her uterus and find out that she is pregnant. We can still discuss exercise, stress and fiber, but she and I have learned a great deal more with just a touch of technology thrown in. Blood tests? maybe not necessary. Followup? If needed, and more likely with an obstetrician.

There are certifications for certain physicians who do point of care ultrasound, which involve taking courses and doing a certain number of procedures which are corroborated by radiologists. Really only emergency medicine has standardized requirements like that, and the rest of us docs are left to invent the standards ourselves. These standards should allow us to use this technology and keep us from doing stupid things like saying or implying that we know things we don't know. Most physicians don't know how to do ultrasound, but many medical residents are now learning it as a matter of course during their training. It seems likely that it will become part of what we do, and that when it does, many of our routines will be streamlined.

The course that I took was excellent, but there are many other ultrasound courses throughout the US which are also excellent, at least that's what some of the other participants told me. The American Institute of Ultrasound in Medicine publishes a list of some of the practical ultrasound courses that are available at this website: http://www.aium.org/cme/events.aspx

Advanced Trauma Life Support

2011-11-09T23:31:00.000-08:00

My 2 year "sabbatical" started a week ago. It has not, so far, involved much sleeping late or eating bon bons, which is fine, I guess. I am working several 24 hour shifts this month for our local hospital, covering the "hospitalist" service. This involves care of hospitalized patients who have no primary doctor or whose primary doctor is unable to take care of them in the hospital. Some of these patients are critically ill, some have fallen through the cracks of our health care system and others have doctors who choose to do only outpatient or specialty practices. In some communities, especially in big cities, doctors who have office practices are just too busy to be available to their patients at the odd times that hospital medicine requires and so nearly all of the patients in the hospital belong to designated hospitalists. In our community, most of the doctors do at least some hospital medicine, which is good for continuity of care.

After quitting my primary care practice the first item on my agenda has been to take some continuing medical education classes that I have been too busy to take in the past, and ones which significantly broaden my scope of practice. The first one that I have done is Advanced Trauma Life Support, a course sponsored by the American College of Surgeons to help bring physicians who treat injured patients up to a basic level of competence in the process and procedures involved in good care.

There are various courses that physicians take that are represented by initials. I have recently updated my skills in ACLS (advanced cardiac life support) and PALS (pediatric advanced life support.) The ACLS course involves memorizing several algorithms for treating patients who present with life threatening heart events. These patients are familiar to me, because internal medicine, my specialty, involves lots of work with cardiac issues. Since my patients very rarely die or threaten to in my presence, it is good to review the steps involved in resuscitating them so that when fast action is required, I don't have to delay while trying to remember what to do. I have taken the course many times, and it is now familiar and easy despite the fact that recommendations change a little bit each time. PALS involved lots of studying and working through scenarios online and then a practical test. It was fine, but not remarkable. I now feel entirely capable of saving digital and rubber babies from various near death events.

I chose to take ATLS because feeling confident in taking care of victims of assaults or motor vehicle accidents is basic to being able to provide emergency care, and I may end up doing some of that. When I decided to take the class I had to find a location that offered it at a time that was convenient. I asked friends who had taken it what their experiences were and I searched online and eventually decided to take the course at Harborview Medical Center in Seattle. I had done several months of residency training at Harborview and found it to be staffed with skilled and committed doctors and nurses who saw lots of very sick and injured people and who were at the front line of innovations to make care better. I wasn't sure that a structured course like ATLS would be different when taught at a major trauma center like Harborview.

The ATLS curriculum started after a doctor crashed his small plane in Nebraska and observed from the inside just how fragmented and inadequate trauma care was. His wife died instantly and three of his children were critically injured. In the year that followed he and others in the medical community began to design a course that would standardize trauma care in a way that would dramatically improve its quality. What is taught now has been changed and honed and continues to change based on research and experience. The class involves lectures and practical sessions, scenarios and written and oral testing. Harborview did a terrific job. The course director, Dr. Sam Arbabi, is a trauma surgeon who is actively involved in caring for injured patients as well as doing research in public health and teaching students and residents. The different systems were covered by a diverse array of surgeons from all over the country, all of whom had different practices and experiences which they incorporated into their course material. The students were also extremely diverse, from small town emergency physicians to surgical residents to primary care physicians who needed trauma background to meet the needs of their injured patients when specialty care was not always available. In some continuing medical education courses, students, despite the fact that they are MDs, are assumed to be stupid. ATLS at Harborview was very collegial. We, the students, were recognized as the front line in trauma care. Patients with multiple severe injuries often end up at Harborview when the small hospitals that initially see them are unable to provide the kind of care that they need. If we, at these small hospitals, take good care of them, Harborview will be much more likely to save them.

We learned a method of thinking about injured patients that allows us to make good decisions when our brains might be overloaded with emotionally relevant pieces of data that can lead to being unable to do the right thing first. The process involves the familiar ABC mnemonic, standing for Airway, Breathing and Circulation. No matter how bad a person looks after being hit by a car or beaten up by a gang or trampled by elephants, if air moves in and out of their lungs and their heart continues to beat, they are alive and their other injuries can be treated in good time. The details of how to do all of this are made up of thousands of hours of training throughout medical school and residency and beyond, but remembering that it is necessary to support movement of breath in and out of the lungs and to staunch bleeding is basic to trauma care and can provide an anchor for the rest of what we do. Beyond this, each professor taught us about a specific area of care, including broken bones, injured brains and spinal cords, lungs which may be popped, contused or bleeding, hearts with similar issues, and the whole collection of innards which work so beautifully when unmolested, but so very poorly when squashed, skewered, perforated or macerated.

The final exam, which leads to certification, involved a practical demonstration of my ability to verbally and physically walk through treatment of a volunteer paramedic or nursing student with gorey makeup and rubber wounds associated with a realistic scenario, such as having been run over by a truck after falling off of a motorcycle or running into a bridge abutment. There was also a wickedly tricky multiple choice exam, with which I didn't entirely agree given the fact that much of what is right to do in any given situation depends on things which aren't possible to clarify in one paragraph. The very last activity of the very last day of the class was a small group discussion of triage of patients in disaster or multiple victim events. Who among the hurt and dying can best benefit from the limited resources available? These discussions allowed us to get to know each other and the course directors better and work through our conflicting values to come up with a consensus that will probably be helpful in future apocalypses.

So the class was excellent. I heartily recommend ATLS at Harborview in Seattle.

As I drove back home, the 5 1/2 hours from Seattle to Idaho, I thought about the fact that the vast majority of traumatic injury that leads to death, disability and dismemberment is directly due to our unconditional love for the internal combustion engine, particularly the automobile. Without motor vehicle crashes, trauma medicine would be a significantly smaller specialty. I clung somewhat more tightly to my steering wheel and drove more slowly and wished I could be footloose without driving my car.

Should you get a flu shot? (plus comments on intranasal and intradermal vaccination)

2011-10-25T22:17:00.000-07:00

Influenza is a nasty viral illness characterized by fever, headache, sore throat, runny nose and a cough. These words don't come close to conveying the actual misery of a real whomping case of the flu. Most of my patients with the flu feel too miserable to come in to the office, which is good, because influenza is very contagious. Not only is it contagious when it first occurs, it remains contagious for 1-2 weeks. But I stray from my description. The patients who do come in to see me with the flu are usually too miserable to adequately describe their symptoms, preferring to moan and answer my questions with short answers. I have had the flu several times, and what I most vividly remember is being nearly unable to move. Usually when I get the flu, I start the day out thinking that I might be getting a little cold, but that I can certainly work. Then the viruses start doubling and infecting my vulnerable cells and I realize that I need to get home. I have traditionally been able to time this pretty well, arriving at my house just before I am completely unable to take another step. I will then sit down on the couch and wait until somebody asks me if I want something at which time I will ask for water which I will be too miserable to drink. Highlights of the symptoms I remember include feeling like my eyes and the linings of my nose had been burned, so I would be unable to either close or keep open my eyelids without pain, hurting in every muscle, whether I moved it or not, mouth dry, bad taste, can't drink because throat hurts too much, racking dry cough. One time years ago my husband and I both came home from work with the flu at the same time, sat down and spent the next 2 hours trying to decide if either of us had energy to reach for the TV control. The flu rarely involves gastrointestinal symptoms, so really does not cause nausea or diarrhea, though the recent H1N1 swine flu was associated with these things, but not to a major extent. The flu is mostly seasonal (though now we have a circulating year round H1N1 from last years over-advertised pandemic) and occurs anytime starting November on up through March. Each year there are 2 major varieties of the flu, an A and a B type, each usually a different serotype than the previous year.

Not only is influenza really unpleasant acutely, it can last for over a week, and then cause a sinus infection that can take weeks to clear or a cough that can persist for months. It can even kill people, either through weakening their systems or from direct effects, such as infecting the brain, causing severe life threatening viral pneumonia or even heart problems. Each year 30-40 thousand people die of direct effects of the flu, which is a huge loss of life and mostly underappreciated. Most of those who die of the flu are very young or very old or weakened by disease, but not all. Some healthy people get the flu and die. In the influenza epidemic of 1917, 50-100 million people died over 3 years it lasted, and they were primarily young and not otherwise ill. Some years, however, flu outbreaks are pretty minimal.

The influenza vaccine has existed since the 1940s, and has been tested extensively since then. Each year now the vaccine is created anew, based on the predicted viruses identities for the next year. Vaccine side effects are usually quite mild, though causing the body to create disease fighting antibodies is sometimes associated with a vaguely ill feeling. People do not get the flu, per se, from the flu shot, though they might become ill in the doctors office while waiting to be vaccinated by being around other coughing and sneezing patients. In 1976 a vaccination aimed at preventing swine flu ended up causing a severe nerve disorder called Guillain Barre syndrome in 1 of 100,000 people who received the shot. Guillain Barre can also happen in a person due to any actual infection, including influenza itself.

Being vaccinated results in a rise in the antibodies that protect against the particular variety of the flu that the vaccine was designed to prevent. In many studies of flu shot effectiveness it has been shown that people who get vaccinated are less likely to go to the hospital, get pneumonia or die. During an influenza outbreak, usually about 1 in 10 people under the age of 19 become infected and it is possible to judge the presence of flu in a community by large numbers of students being absent from school. Vaccinated healthy people are less likely to miss work during flu season and vaccinated elderly people have a 68% reduction in death during flu season. Some of this effect may be due to the fact that healthier and more affluent elderly people are more likely to be vaccinated than the poor and homebound, but this does not entirely explain the effect. Healthy vaccine recipients are significantly more likely to have good immune response to the vaccine than elderly or very young or otherwise medically vulnerable people, so their protection from the virus is probably correspondingly higher. Some years vaccine designers guess wrong about which influenza virus will be the most prevalent and so there have been years when the vaccine was all but useless. Production of enough antibody after vaccination to protect against flu varies significantly for different subgroups of people, from as low as 20-30% in older adults and as high as over 60% in healthy volunteers. The fact that the only a small proportion of the elderly respond to flu vaccines in any measurable way, and yet their death rate during the flu season is profoundly reduced does bring into question whether getting the flu shot is merely a marker of good health rather than protecting against disease.

Each year about 100million people receive the flu shot in the US. Some much smaller number of people are vaccinated by the nasal route, receiving, instead of an inactivated vaccine, a live virus that infects the body without causing harm, thus raising the flu related antibodies more naturally. Evidence suggests that this route of vaccination may be more effective in children, but recent studies have overall shown more influenza type disease in recipients of the live vaccine. The more common, inactivated flu vaccine is given as a shot in the upper arm, into the muscle. It can cause aching that may last a few days, and occasionally causes significant swelling. Two years ago when there was a vaccine shortage information was released showing that injection just under the skin into the subcutaneous tissue of 1/5th of the volume of a standard flu shot was at least as effective as the intramuscular injection. It was suggested that physicians might be able to give more shots to more people with less vaccine if they did the vaccination this way. This year, as an experiment, I vaccinated myself and my family with a smaller than standard dose of flu vaccine subcutaneously. We all felt that it stung a little bit more, but didn't ache as deeply as the intramuscular route but was otherwise a little bit superior due to the shorter and tinier needle that is usually used for that type of injection. I have been curious, for the last two years, about why a subcutaneous injection of the flu vaccine had not become standard of care if it works better and utilizes fewer resources. Vaccines are very big business, though I'm not sure exactly what the numbers are. The biggest manufacturers of influenza vaccine are Sanofi Pasteur and Glaxo Smith Kline. If they make even 2 dollars per shot, which is probably a low estimate, the profits would be $200 million dollars in the US alone. If influenza shots were given subcutaneously, the world could get by with 1/5th the amount of vaccine, significantly reducing profits. But I just read in the Medical Letter today that Sanofi Pasteur has figured out how to avoid that pitfall of cost savings by producing a single dose subcutaneous injection of flu vaccine for...only $4 more per dose than their standard flu vaccine which costs the pharmacist or physician $12! Clever Sanofi Pasteur. If we physicians are not mindless sheep, however, we will figure out that we can start giving 1/5th size subcutaneous flu shots with tiny little needles in the not to distant future.

So--bottom line--should you get a flu shot? Probably yes. If you are healthy, your antibody response will be robust and you will be less likely to get the flu this year, miss work, feel terrible and possibly (but not likely) die. If you are very old or infirm, your immune response will be less but your downside should you get sick is significantly higher, and might more reasonably include dying. It also seems clear that more research is needed to define exactly who will benefit from flu shots, and that the ethics of withholding flu shots from a random group of people in order to do good science is complex. If it turns out that flu shots really don't protect well from death and disease, we are wasting a colossal amount of resources in vaccinating everybody as we are now.

What is the very best way to prevent the flu? Probably by avoiding exposure to sick people by having more comprehensive policies to discourage sick people from going to work and school. This will never be perfectly effective due to the fact that people can be significantly contagious before they get sick enough to realize that they need to be home. That said, I do wonder if even this approach is optimal. It may be that frequent exposure to germs in levels insufficient to cause actual disease might serve to immunize those exposed and make them less likely to catch or spread the disease in the future.

Flu shots are available to anyone at a cost of about $25 a pop at grocery stores and pharmacies and are covered by virtually all insurance companies. They are usually offered to patients starting in late September commercially, but since immunity only lasts for 3-4 months and outbreaks frequently occur after January, waiting to get the vaccine until the end of October is recommended. In the US flu vaccine is recommended for all people over the age of 6 months, including pregnant mothers. It is particularly recommended for healthcare workers who are more often exposed and who have a higher likelihood of spreading the disease to vulnerable populations.

The perfect electronic medical record

2011-10-22T11:05:00.000-07:00

I have had a love hate relationship with our computerized medical record since we first started using it in 2007. Much like computers in all of American society, the idea that our computerized medical record is just a small facet of what we do, involved in the storage of information, is a gross simplification. In the US (also elsewhere, but I can't speak for Europe or Asia from much personal experience) the ubiquitous presence of computers has affected how we work, play, think, communicate. These interfaces with brains that we use so frequently have made us fatter, more connected to each others' thoughts, less connected to each others' bodies, has reduced our ability to use non-visual senses, has partially convinced us that 3 dimensions are optional, and I could go on for hours (at which time all hope of going out for a walk would be gone.) In my medical office, my near-umbilical connection to my laptop has touched all parts of what I do. The production of a document, which integrates information from as many sources as I am aware of that refer to my patient, is one of the most important goals of a visit. I also try to solve the patient's problem and answer their questions and listen to them, but I do it within the context of my computerized medical record. This sounds overstated, but in my particular case I think it is pretty accurate. So the fact that our particular software package sucks is profoundly irritating.

Now "sucks" is a pretty strong word, and I only use it because we just had an update which has been as infested with bugs as a cheap motel and I am frustrated. Oh so slow. I feel like some sort of a bivalve sea creature as I wait for the screen to allow me access to my patient's vital information. I feel trapped and claustrophobic as I attempt to stay within one layer of the record while needing simple information such as what happened last time or how old they are, that exists but is clicks away. The love part of "love hate" comes in when I see how many great features there are, including the ability to communicate to other doctors in my practice and support staff and pharmacies in a way that is accurate and nearly instant, and the fact that I can organize and transmit information that is coordinated and readable to the patient or to unconnected physicians in a printed format. That doesn't sound like much, though, in return for essentially marrying a computer.

I can, however, imagine a computerized medical record that I would really love, and have been doing that exercise for the last few days. I will now state what I want, and maybe at some time in the future, the universe will provide.

I would like my documentation system (EMR, for electronic medical record) to allow me to record information quickly and efficiently. I would like it to remind me to do things that I don't want to be thinking about while I am trying to concentrate on listening to my patient and formulating a reply or solution or whatever is called for. I want my EMR to keep me from doing obviously stupid things. I would also like it to tell me how late I am getting for my next patient. This is not much to ask, and I know computers can do this stuff. In fact, it may be that somebody's EMR somewhere in the world does do this.

When I first sit down with a patient, my nurse has been in the room, has gotten vital signs (blood pressure, weight, pulse, temperature) and, time allowing, has asked what issues the patient has and even typed them up in the medical record (yay Joy, you are an awesome nurse.) I would like my EMR to have already given my patient a chance to answer some of the more routine questions, such as "is this really your medication list?" and "in addition to your issues today, do you have any alarming symptoms such as passing blood or fainting or chest pain?" When I first looked at the screen it would show me a summary of the most recent medical visit and labs, so I would be reminded of salient information. I would then like to have a discussion with my patient about what they want help with and the stories, questions and answers surrounding that (the history of present illness.) I then want my computer to prompt me to ask questions about the corresponding systems. (Patient says "trouble swallowing", computer brings up review of nose throat and intestinal system "do you have post nasal drip, cough with eating, vomiting, heartburn or blood in the stool".) I then want it to remind me to review the background information: still in the same job? marriage? family history, clues to stress related issues? medical history? Then I will do my physical exam. I want it to highlight any abnormalities of the vital signs (sometimes I don't notice until later that the patient's blood pressure was elevated) and come up with a form to document my exam that is consistent with what I normally do. After I finish that, I would like it to highlight any area that the complaint suggests would need more careful examination. Then I want it to ask me what medical orders I wish to add and which medications I wish to prescribe or change. If I order a medication that interacts with another or that the patient is allergic to, I would like it to tell me (it does this now, but in such a ridiculously lame way that it is unusable). If I order a test or procedure that has been done or ordered in the last year, it should tell me that, too. Then I want it to suggest patient education handouts which I would press a button to print out. I would then tell the patient what I am thinking, ask if they had any other questions and the EMR would notify the nurse to come back in and it would lead her through a brief review of preventive medicine recommendations to tell the patient (due for a mammogram, stuff like that), but only once or twice yearly for any given patient. The nurse would also then make sure the patient had prescriptions and followup information which would already be clearly documented in the record. As far as reminding me how late I am, I would like there to be an appointment bar at the edge with present time and color coding and actual numbers to indicate how long my upcoming patients have been waiting.

Could I go through all of this in a 15 minute appointment? Depending on the complexity of the problem, most likely yes. Would the patient feel heard and supported? I think yes. I know for sure that if I spent less time in combat with stupid evil software I would have more mind and heart to spend on being a human helping another human in need.

Computerized medical records are here to stay because their potential for improvement in communication is so awesome. The most important trick is for us to make them facilitate real care of patients rather than let them suck us into their information vortex only to have us lose sight of what we as caregivers are for.

Telemedicine: where could it lead?

2011-10-19T21:25:00.000-07:00

I have only 6 more days in my present job as a primary care internist in my home town. The process of wrapping things up has been new and time consuming, but ultimately very rewarding. I get to see patients I've known for over a decade, in some instances, and review what has happened with their lives and their health and we work on future plans for maintaining what they have gained and getting a handle on problems still bothering them. We say goodbyes and good lucks and talk about the important, big stuff, like hopes and dreams and medication refills. Interspersed among these appointments and phone calls are multiple communications about my next job, whatever that will turn out to be.

I am signed up with 2 locums companies, and in contact with 4 recruiters who are my agents, as well as the recruiters that are associated with my possible new jobs. The phone calls are mostly really interesting, since I get to hear about new places and how they are doing what they do in health care. Many of the jobs that sound perfect have been non-starters because they need me at times when I can't be there, or for lengths of time that would take me away from my family for too long. Primary care positions would like me to be around Monday through Friday, with the occasional call weekend in some cases, for 3 months. This could work if they are within a reasonable traveling distance of my home and family, which does cut down on my options. Hospitalist positions, where I would take care of just patients in hospital, usually for 12 hours each day, are considered full time if I work 1 week on and one week off. If they are willing to fly me in and out, and the location is within a reasonable distance of an airport, that could work anywhere in the country. I would not have to be away for so long that my dog forgets who I am. Of all the jobs I could get, I would prefer "traditional internal medicine" which involves both outpatient and inpatient work because I think it will teach me more about a whole community and how it is coordinated to do health care. It is good locum tenens etiquette to apply for only one position at a time, which can lead to serial disappointments and presently I remain on the edge of my seat as I wait for confirmation of my first assignment. I'm sure it will be just fine and dandy, whatever it is, but it would be so reassuring to know where I will be in 2 months.

My resources for this adventure (my 2 years off from my regular primary practice) include quite a few friends and colleagues who have done or are still doing locum tenens (latin for "place holder") work. They tell me what places they have liked, where the ethics or the support might be thin, which companies take care of their clients. Sometimes they even know of specific needs, where I might work without using a recruiter at all. One such opportunity is doing telemedicine. Telemedicine is the practice of taking care of patients remotely, using telephone or computer. It is often practiced in places where the right doctor cannot be present physically, such as when a rare specialist is needed in a tiny hospital. It is used to share expertise over great distances, and is used internationally by some medical aid organizations. At the recommendation of a friend, I contacted an organization called MDLivecare, which provides telehealth services domestically, with private clients (people who arrange e-visits on their own) and corporate subscribers. A large company may wish to provide their employees with a way to contact a physician quickly, easily and inexpensively as a way to reduce time lost from work and in order to provide services more inexpensively. The telehealth visits include many of the trimmings of a real doctor visit, including documentation of what was discussed, communication with the primary care physician if there is one, and even prescription of medications (though controlled substances are strictly out.)

At some point in the future I will probably know more about telemedicine because I will probably try doing it. I have always enjoyed the challenge of treating patients over the phone, and having a video chat interface will be even easier than that. Much can be communicated verbally, and though loss of the touch aspect of medicine is a considerable hindrance to some diagnoses, I think it will be really interesting to see how much can be done in this type of an encounter.

Yesterday I visited with a patient who had a very odd neurological problem, a "funny walk" that was new and didn't really fit into patterns I had seen before. More than anything, I wanted her to be able to see a world class neurologist, who could probably ask a couple of questions, watch her walk down the hall and know what she had. But we were in a small town in a small state, and getting to a world class neurologist is probably nearly beyond her. It would be so simple, if telemedicine were more widely accepted, to call my favorite world class neurologist, web cam her funny walk, tell him my concerns and ask any questions he might have and get our answer. What presently hinders this are the fact that even practicing telemedicine requires a state license, and that there are no easy ways to bill for this service. Clearly that needs to change. We have technology at our fingertips that would reduce human suffering and we are hamstrung in our ability to use it. I look forward to the inevitable adjustments in payment schemes and regulations that will allow us to use what we have to its best advantage.

Meaningful use: the top heavy nit picky route to possibly better health care

2011-10-05T22:10:00.000-07:00

As part of the 2009 American Recovery and Reinvestment act (the massive stimulus package enacted at the beginning of our economic slump) doctors were offered money to start using computerized medical records for their patients insured by Medicare and Medicaid. It was felt to be evident at that time that use of a computers to document patients' medical encounters would make communication between providers better, reduce errors, reduce redundancy of testing and procedures and overall streamline documentation. Many physicians had already started on the road to making their records digital, but government support made others take the big step. Our office bought a very expensive computer software package from GE along with all of the hardware to support it in 2007, and by the time the stimulus package passed, we had almost adjusted to the change. We figured we would probably be well set up to be rewarded for having made this momentous change before the majority of offices.

Adjusting to an electronic health record (EHR) is not easy. The programs for keeping such records are extremely complex, owing to the demands of privacy, legal issues, communication with other entities, drug prescribing, and the fact that most of these programs have been written over many years by programmers who no longer work for the same company and are no longer around to explain the rationale of the code they wrote, much less to fix it. The resulting products do really weird things and don't do some of the normal things that one would expect them to do. They don't automatically check spelling, for instance. They do lag, significantly. Perfectly simple tasks make them crash, and though these bugs are fixed, they reappear whenever there is an update. Of course, my experience is with GE's product, in our office, and doesn't necessarily apply to all EHRs, but from what I hear, many of them are plagued with the same problems.

In our office in the weeks following changing from dictating or writing our notes and communicating our plans orally or in handwritten notes to doing about all of this with a computer interface, our productivity dropped precipitously. If we could see half the number of patients we had seen prior to EHR it was a good day. People, including physicians, cried, yelled, quit their jobs. It was kind of awful. We had sick people to treat, and we couldn't access their histories, write their prescriptions, and we would sit with them, powerless in front of a computer screen that would not navigate to what we needed. After a couple of years we had almost become as fast as we were before computers, but truly we have never entirely recovered. Some things are definitely better. Our notes are readable. We know what we have prescribed and when. We are reminded of schedules for vaccinations and that sort of thing. We can produce a nice looking typed note for work in a couple of minutes. But we still spend lots of time staring at a screen rather than focusing on a patient and I, personally, am still slower, even though I am quite comfortable with computers.

It was a disappointment when we learned, about a year ago, that our computer system did not qualify us for any sort of reward through the Recovery and Reinvestment Act. What was required was "meaningful use" of an electronic health record. How, we wondered, were we to make it meaningful? It sure felt meaningful to us. The cost of it was pretty meaningful: over $100,000 for the initial investment, plus more than that much in updates and lost productivity. For a bunch more money, we found out, we could have "meaningful use" and be eligible for some payments. We have embarked on that road, and a rocky one it is.

Meaningful use requires 15 "core measures" be met along with 5 out of 10 menu items. We don't have do do every one with every patient, at least not yet, but we need to make a good start. The 15 core measures are:
1. We need to enter our orders (for things like tests and consults) on the computer.
2. We need to have the drug ordering part of the program be set up to tell us about drug interactions.
3. We need to keep an updated computerized problem list for each patient.
4. We have to transmit our prescriptions electronically, those that legally can be sent that way.
5 and 6. We have to keep active medication and allergy lists.
7. We have to keep demographic information of everybody, stuff like age, sex, language and ethnicity.
8. We have to keep record of all vital signs, including the body mass index and be able to graph growth in children.
9. We need to document whether the patient smokes (age 13 and older.)
10. We need to be able to transmit clinical quality data to Medicare.
11. We need to have our EHR help us make clinical decisions about at least one condition.
12. We need to supply patients with a summary of their health record on demand, including diagnoses, allergies, medications.
13. Within 3 days of a visit, the patient needs to receive a summary of their visit, including their problems
medication changes, what referrals were made and to whom, with contact information and what followup was recommended
14. We need to be able to transmit medical records to other providers electronically.
15. Our records must be secure.
The 10 menu items, from which we can choose 5, require that we:
1. Check insurance formularies so that patients know if the prescribed drug is covered and what other options are available.
2. Have lab tests be entered in such a way that the EHR can search them and use that data in various ways (i.e. not a scanned image.)
3. Generate lists of patients with specific condition.
4. Send patients reminders for followup for certain conditions and for prevention.
5. Provide patients with electronic access to their health information within 4 days of results being available.
6. Provide patient specific education resources (I think this means things like handouts on specific diseases.)
7. Do "medication reconciliation" -- making sure that medication lists from each provider are the same.
8. Provide summaries of care when a patient is transferred from one doctor to another.
9. Electronically submit vaccination data to agencies that collect that data.
10. Submit data on diseases or syndromes observed to appropriate agencies (like Dept of Health for infectious disease outbreaks.)

Most of these requirements are both reasonable and a good idea. Some of them are a really great idea, but figuring out how to do them is going to be a bear. The main one that has me worried is the summary of the patient visit. I used to write summary letters to patients after their yearly physicals. It took forever. Not only did I need to document the visit for my chart, I had to rewrite it in a way that a patient would understand. It just about doubled the amount of time it took to document a visit. It was also a great gesture, and I'm sure the patients usually benefited from it and appreciated it. I won't deny it is a good idea, but with the slowness of computer documentation as it is now, I wonder where we will find the time. I'm pretty sure that even a good computer can't take the data from a doctor's visit and turn it into prose that will be comprehensible to a real person, so to the extent that these documents are really useful, they will have to be generated by the doctor. We are expecting a bunch of new patients to be needing primary care doctors in the next several years, associated with a shortage of these providers, which will make it nearly impossible to spend more time in documentation.

Another thing that worries me is the requirement to submit data on quality to Medicare. Some measures health care quality are deeply meaningful, for instance, is the patient happier and healthier due to a medical encounter? Unfortunately, those outcomes are difficult to measure. Instead we measure whether diabetic patients have their blood sugars below a certain, somewhat arbitrary number, or whether women over a certain age have gotten mammograms. Many of the things that we decide are good and important in health care turn out to be not good when the next study comes out. For instance, we found that vitamin E wasn't good for anything, then found that it effectively treats fatty liver in obese patients. We still disagree about how often to get mammograms on patients, and screening for prostate cancer is a hotly disputed topic.

The updates to make our computer systems jump through these hoops will make us tear out our hair, once again, and stare helplessly at poorly functioning screens while sick patient wait for our help. I still hope that one day the intelligent and computer savvy generation behind me will be hired by Medicare to produce an EHR that is as lithe, supple and fast as a cheetah and we will all use that wonderful product which will be affordable due to economies of scale. I'm waiting eagerly. If that cheetah-like EHR comes to exist, it may well improve efficiency, reduce error and lead to better communication.

So how much money is offered to physicians who choose to attempt meaningful use? If we achieve this in 2011, we get $18,000 each. In 2012 we would get 12K, in 2013, 8K, 2015 4K and then in 2015, if we haven't achieved it, we will be penalized 1% of our medicare payment, then 2% the following year. If it takes until 2012, we only get 3 years of bonus, and so on. At most we can make $44,000 from meaningful use. That is a lot of money. It is also a drop in the bucket compared to what we will have spent in computer software, hardware and lost productivity. But that cat is out of the bag, and $44,000 is still a lot of money. The present meaningful use criteria will be replaced by stricter criteria, and it is not at all clear what those will be.

I'm not entirely sure what to think of this whole process. It seems that we are scurrying in vaguely the right direction, with better patient care as a goal, and an electronic health record as a tool to reach that goal. The way we are going about it, however, seems haphazard and destabilizing. Our aversion to truly standardizing our concepts of quality and our medical records is making these transitions much more difficult that they need to be.

Patient Centered Outcomes Research--a good start

2011-09-28T21:08:00.000-07:00

The affordable care act, in its 2000 plus pages, provided for many projects with the potential to improve health care delivery in the US. The most actively debated part of the bill, the mandate to insure just about everyone, may not turn out to be the most important piece. The problems the affordable care act attempted to address are the fact that American health care spending is too high and buys too little, including poor outcomes for those who do get health care and the fact that too few people who need health care actually receive it. All of these issues are addressed in some way or another in the myriad provisions of the bill.

One rarely advertised provision of the bill is the Patient Centered Outcomes Research Institute (PCORI). This is a private institute, publicly funded, which includes a huge diversity of players, from patients to providers and sundry others, who are charged with figuring out exactly what Patient Centered Outcomes Research is, and then making it happen and disseminating the results. According to a recent article in the New England Journal of Medicine, they have been holding meetings, many of them public, just to figure out what it is that they feel they should do and how they will most effectively do that thing. At this point the groundwork is mostly done.

The PCORI has decided that its prime directive is to help patients answer these 4 questions:

“Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”
“What are my options and what are the benefits and harms of those options?”
“What can I do to improve the outcomes that are most important to me?”
“How can the health care system improve my chances of achieving the outcomes I prefer?

Given the present scurrying behavior of most physicians to try to develop systems to help them practice evidence based medicine which will theoretically pay them more for reaching certain benchmarks in treating various common diseases, these patient centered questions are very relevant and an absolute necessity. As we as physicians begin to see our paychecks depend upon whether our diabetic patients are getting statin medications to prevent heart attacks and maintaining certain blood glucose levels, we vitally need to be reminded that our job is truly to improve patients' lives. That means adjusting what we do to respond to those patients' educated preferences. Results of patient centered outcomes research may help us do that.

I have some misgivings about the PCORI. It is very large. I can't quite figure out how large, but large enough that it sounds as if decision making is slow going. That will not slow the research that they fund, since that can be done by small groups with good ideas. Still, implementing change based on new research may be slow. I also wonder how information that helps doctors and patients make individualized decisions about care will interact with the freight train of "pay for performance" based on scientific evidence which usually demands strict adherence to a protocol.

I presently choose to have faith that the process of patient centered outcomes research will eventually meet up with pay for performance and we will actually be paid for the performance of individualized care for patients who are undeniably individuals with individual needs and preferences. It is just possible that the truth shall set us free.

Physician non-compete clauses--another way to gut rural health care

2011-09-24T18:17:00.000-07:00

Lately I have been dealing with the painful process of separating from my medical group. I have been part of this group since its inception, about 12 years ago. It serves two small towns in adjacent states and has about 30 employees and 12 providers, mostly located in the larger of our two clinics, in which I do not work. We originally came together from 3 primary care practices in order to share resources and reduce overhead. Cultures and values were somewhat different, but we did all care about delivering good quality medicine, letting our physicians have autonomy in decision making, and about making sure that each one of us could have lives that were humane, valuing family time or outside interests and covering each others' patient's needs so that care would not suffer.

When we came together we wrote a contract which was longer and more formal than any I had signed before and had various elements that made me somewhat uncomfortable. One was the "buy-in". This was an amount of money that we all agreed to put in to essentially buy the practice. I balked at the size of this, since my location of practice was very inexpensive, and the physicians in the larger office were "buying in" to a large and brand new medical office building. My concerns were respected, and my buy-in was smaller, as was that of my two partners. The other issue was a non-compete clause, which I was told was standard and non-negotiable. This clause in the contract stated that if my employment with the corporation ended, I would not practice medicine within 20 miles for 2 years.

Physician non-compete clauses are strongly disfavored by the American Medical Association and considered unethical. They restrict choice of practice and they penalize patients when a physician is at odds with his or her employer. They are hard to enforce and void in some states, most prominently California. They have been viewed as restrictions on trade, though various interpretations of this have arisen from court cases. They remain a common component of physician contracts. They are particularly hard to enforce if it can be shown that the physician is needed in his or her community and that enforcement of the clause will harm patients.

In the case of me and my clinic partner, who are obliged to sever our connection to our parent organization because our clinic is no longer viable after loss of half of our provider staff, there are a multitude of reasons why a non-compete clause is going to be unenforceable. The most important of these involves the patients in the community. Our town of just over 20,000 people now will have 2 rather than 4 internal medicine physicians, which is inadequate for our aging population. In another practice in town which has an even more restrictive non-compete clause, physicians are unable to make changes that might be in everyone's best interest, since if they leave the practice they must also leave the community and most of them are strongly tied to it, with children in school and spouses with jobs.

If a non-compete clause is unenforceable, unethical and disfavored by our national organization, why do we even worry about it? It is very common for an organization to threaten to enforce a non-compete clause, and to have this happen would be painful or disastrous. Court cases such as these cost 10s of thousands of dollars to complete and result in frequent and unpredictable time commitments that make it difficult or impossible to concentrate on a medical practice.

I have chosen to do a 2 year sabbatical at the end of my association with my present group for many reasons, and mostly because I really want to and think that the experience and knowledge I will pick up will be positively transforming in ways that I can't predict. But I would like to be able to fill in here or there in my community if I am needed during those two years. I can do the exile thing, but it is hardly good for my patients or colleagues, including those at the corporation I am leaving. Nevertheless, sabers are rattling and threats being spoken. My colleague is experiencing the same constraints. It affects both the community and our families, who will be mightily disrupted by our departure or frequent absences.

I have learned an important lesson, which I will not have trouble remembering. I will NEVER sign another contract which contains a non-compete clause.

http://www.wahcnews.com/newsletters/wa-jshore1210.pdf provides a lawyerly review of some of the issues.

http://www.gklaw.com/news.cfm?action=pub_detail&publication_id=842 presents a bit more on the AMAs position.

http://www.doctoremploymentlawyer.com/2011/08/physician-non-competes-being-e.html recognizes the power of the threat of enforcement.

Who wants me?

2011-09-21T21:55:00.000-07:00

Today was filled with the usual stuff, which is actually never the same from day to day. My first patient of the day dropped in because she was having a stroke. She was actually my partner's patient, but I knew her pretty well from a previous visit and was happy to be able to help her out. I was also wickedly late for my first scheduled patient who just needed a preventive physical exam. Both were good interactions, understanding people with commendable patience (especially the one who waited an hour) and despite being clearly way behind for the rest of the day, it was what I love to do.

I have been more late, of late, because all of my routine appointments involve an explanation of what I'm doing when I quit my job next month, a recommendation for what to do for any health care needs, including a pretty exhaustive review of all of the doctors in the community who might be appropriate matches and some kind of heartfelt recognition of the length and depth of our doctor-patient relationship. This takes awhile, but is necessary and valuable. I have taken care of some of my patients for 17 years, and that means lots of stories told and heard, trust won and compromises hammered out. These are mini-divorces. They are not acrimonious, but they are intense. And then, of course, there is also the problem that the patient is having at the moment to be heard and maybe solved. My agenda at these appointments also involves looking at the whole set of problems and trying to make sure that we both have a clear view of the best strategies for getting them solved and that any loose ends are tied up.

The number of patient for whom a physician is responsible is difficult to glean from our medical records, due to the fact that many patients see a doctor only rarely, or see different doctors based on availability. But based on my official patient panel size when I worked for Group Health, and based on information from an internal medicine preceptor of mine many years ago, a full time physician might have 1800-3000 patients who regard them as "my doctor." The doctor patient relationship is important to most of these patients, even if they are seen infrequently, I am finding out. Some of the people who are most unhappy to see me go are people I see at most once a year. They don't come in with every ailment, but the fact that I exist and know them is really important to their feeling safe. At least that's what it sounds like.

But I'm not just doing this important doctor patient stuff, I'm also trying to find a job.

A primary care internist who is well educated, board certified, speaks English and hasn't done anything reprehensible is in demand in the US. I will find a job. The easiest of jobs to find will be in places that are very hard to get to, in rural areas where there are desperate doctor shortages.

When I first decided to contact a locum tenens recruiter, I went to the organization which had an excellent reputation with a locum tenens surgeon who I respected. I called them and was immediately put in contact with a man who told me a little bit about the whole process. He told me which states really needed physicians, what different jobs paid, that sort of thing, and tactfully tried to ascertain what awful skeleton in my closet was leading me to look for work. I told him my story of planned adventure, and he told me that anything was possible. He failed to outright relieve me of my misapprehensions about how I could get a really short term job anywhere I wanted whenever I wanted and be home with my family lots. He did that acquiescent groveling thing that representatives of drug companies do when they try to get me to use medications of dubious utility and ridiculously high cost. I tried to be reassuring so he would treat me like a regular person and give me straight advice, but it took over a month for me to realize that unless I wanted to go somewhere and work really hard for 3 or more months straight and then consider moving there, I was going to be looking at 12 hour hospital shifts or really remote locations with really not enough doctors to handle the patient volumes.

Just two days ago I finally decided I needed to contact a larger company with more job opportunities. I was immediately put in contact with two people who seemed more than capable of making me understand how the process works. There were several jobs that sounded possible, if not perfect. And today, through the first guy, I got a call from a very jolly, clearly English as a second language family practitioner from a microscopic town in Wisconsin not far from the Canadian border, and frankly it sounds pretty sweet. We shall see what comes of all of this.

Walk, sing, practice medicine

2011-09-19T21:43:00.000-07:00

I have worked as a primary care internal medicine doctor in a small university town for the last 17 years and have loved it more each year. I like my office, I feel at home and appreciated at the hospital across the street where I care for patients I know and for some who I eventually get to know through doctoring them. I can do intensive care medicine, take care of patients with delicate social situations and pick up the medical pieces with patients who have surgeries or injuries. It is never dull and it only rarely makes me feel sad or frustrated. I know the nurses well, count on them and am almost never disappointed. My relationships with my fellow physicians are warm and I respect them.

On October 31 of this year I am quitting my job. I am not old, so I am not retiring. It's just time to do something else. Various things happened which were the universe's way of telling me that I needed to do something different. My nurse practitioner partner with whom I shared an office, a world view and plans for future brilliant schemes, died suddenly in April, and one of 3 remaining partners in my clinic decided to take a job elsewhere as a kind of partial retirement. It is not possible to effectively hire another internal medicine doctor for a clinic such as ours in a small town such as ours with any degree of certainty, and my remaining partner and I were becoming swamped. It is possible to keep up with the level of work we were doing for a few months, but not for the rest of my work life.

My plan is to get as many experiences as possible practicing medicine as many places and settings as I can for the next two years. I want to see how other people do what I do, how other systems work, how they don't work, what they smell like, feel like, taste like. I would also like to take long walks in places I've never been, and since I'm asking for what I want, sing. I love singing with people and it is a hobby that is not hard to indulge. I especially like singing with small groups in harmony. But more about that later, perhaps. I bet I'll be able to squeeze some good music into the next year or two. I will also take lots of delicious continuing medical education courses and learn from academics how to do things that I don't know how to do.

I'm calling it a sabbatical. The term "walkabout" would also be accurate. That term, as I understand it, refers to native Australian's need to leave what they are doing and do something else, somewhere else, for a time. It's a fascinating concept, but it is not entirely clear how it's going to work. I have started to look into my options by signing up with a locums company, a group that will find me jobs in places where they desperately need a doctor to fill in for a time. Ideally, these positions would be for just long enough for me to experience a new place and get familiar with their routines, meet new people, explore my new communities. I'm finding out, though, that jobs want me for as long as possible, as full time as possible, and preferably they would like me to eventually move there and take the job full time.

I would also like to go back to Haiti, to La Gonave, and work with the communities that I have started to get to know on public health issues such as birth control, safe sex, contraception and building healthcare teams. This is expensive for me, but will be less expensive when I am not having to pay a staff and an office to run in my absence.

I also plan to work in a rather remote clinic in Alaska where a friend of mine has worked for years, intermittently, but probably not starting in the dead of winter. I will work this out myself, with the help of the hospital administrator there.

Locum tenens companies, like the one I signed up with, take care of the details of credentialing, malpractice insurance, arranging licenses, travel, housing and any money negotiations that have to happen. They also charge a lot of money for doing this, which is absorbed by the poor desperate hospital or clinic that uses their services to fill a slot. This means that, by participating in this process I will be directly contributing to high health care costs. I do like the idea of having everything arranged, but in the best of all possible worlds, I will find at least some of my own jobs and negotiate the details myself.

Other than the fact that I am leaving my patients and community in a lurch, this is a great plan. I get the idea, though, that it won't go particularly smoothly. It seems entirely possible that I won't get exactly what I want, and sometimes not vaguely what I want. I am expecting that by the process of trying various things, failing and succeeding, I will learn lots of amazing stuff, including how to do this thing that I'm going to be doing. If I do figure that out, maybe it will make this kind of thing easier for other physicians to do. The reason that it is a great idea is that medical practices are kind of like little Galapagos islands, developing procedures, tricks, solutions that they never share with other groups. Deliberately learning new stuff and sharing it just has to be something that holds hope for improving medical care and efficiency.

I will be using this blog to document my adventures, should I have them, and the perils and pitfalls of getting this stuff all arranged. I will also continue to write about the wonderful tidbits of American medical care in its glory and absurdity as I have been doing.

Is Lipitor good for you?--putting statins on the hot seat

2011-08-30T22:38:00.000-07:00

In 1971, as medical science was wrestling with the observation that elevation of cholesterol levels was associated with heart attacks, a Japanese chemist named Akira Endo discovered a substance that inhibited the enzyme HMG CoA reductase and thus lowered cholesterol levels. His original chemical was never introduced due to significant muscle toxicity and the fact that it caused tumors, but not long after, a less toxic version was introduced under the brand name Mevacor (Lovastatin.) This drug was significantly more powerful in lowering cholesterol levels than the unpleasant and relatively ineffective drugs that came before. These are still used today, but are difficult to take, including ones that taste like sand and absorb cholesterol from the gut as well as high dose niacin which causes itching, flushing, worsens diabetes and exacerbates gout. Lovastatin could be dosed once daily, was an innocuous capsule, and lowered cholesterol strikingly.

Since that time, many more HMG CoA reductase inhibitors (statins) have been released, and they all work pretty well. That is, they all work pretty well to lower cholesterol. It is true that high cholesterol is strongly associated with vascular disease, especially heart attacks and strokes, and that use of these drugs does reduce the risk of these things. Unfortunately, it is not entirely clear that these drugs make most people healthier or make them live longer.

Many good controlled trials have shown that statins, pretty much all of the statins, and there are quite a few, reduce the risk of vascular disease AND DEATH in people who have had heart attacks or vascular procedures to prevent heart attacks. But if statins were only used in those already affected, sales would not have topped $12 billion for lipitor (atorvastatin.) A recent meta-analysis evaluating all good studies of all statins did show that normal people with elevated cholesterol who were treated with statins did not live longer than those who were not treated.

There have been many many studies that have addressed the effectiveness of statins, partly due to the fact that there is so much money going into paying for these drugs, some of which can be routed back into science. The studies address risk of all kinds of diseases, vascular and otherwise, in all kinds of people, especially sicker subpopulations. It appears, for instance, that the very old who have had heart attacks do live longer if given statins. Diabetics, at least some diabetics, have less heart attacks and strokes, and live longer when given statins regardless of their cholesterol numbers.

Statins are very powerful drugs. They work to keep the liver from making cholesterol, but they also have some pretty diverse other effects, including stabilizing blood vessels and reducing inflammation that can cause heart attacks. They also are somewhat toxic to mitochondria, the tiny cells within cells that are responsible for the health of a myriad of different tissues in our bodies. Because they sometimes injure mitochondria, they can cause muscle pain, and in some cases dangerous breakdown of muscle tissue. The muscle pain is associated with damage that can be seen on muscle biopsy, which is usually, but not always, reversible when the drug is stopped. Other tissues that can be affected include liver, kidneys, gut and brain, and a small percentage of patients who take these drugs have symptoms that arise from these effects. Muscle pain, however, is not rare, and in my practice requires stopping the statin drug in about 1/4 of patients who would like to be able to take these medications. Symptoms associated with statins can be really subtle and many patients who experience them assume that they are just getting old. Physicians are not very sensitive to the possibility of side effects with these drugs, partly because they are such an easy way to get cholesterol down.

If an evil alien race wanted to take over the world, statin drugs might be just the ticket. They would make those who are already damaged by heart disease live longer, and cause some portion of the rest of those taking them to become weak, flatulent and stupid. A drug that was indicated for a condition such as high cholesterol, that affects nearly 1/4 of people in developed countries and offers to reduce their risk of heart attacks and strokes would be so very tempting that most of us would take it. Clever aliens.

There is near consensus among academic physicians that statins are good for us, and that complaints about side effects are overblown and irrelevant. I am having trouble trying to find support for this in the literature, and real trouble ignoring the side effects that I see in my office. It is hard to ignore the power to sway us that may be wielded by a drug company that makes 9 billion dollars in a year on one of these drugs, as Pfizer does on Lipitor.

A couple of other matters deserve note. There are quite a few statins, from the less potent pravastatin, lovastatin and fluvastatin, up through the most powerful, simvastatin, atorvastatin, rosuvastatin and pitavastatin. Several are generic, and of these, the most popular is simvastatin due to its low cost and high potency. All of the statins can cause adverse reactions, but some are worse than others. Simvastatin is probably the most likely of all of them to cause muscle pain and to interact with other drugs in ways that increase those side effects. Drugs that interact with some or all statins include various antibiotics, warfarin, antifungal and AIDS drugs and as little as a cup of grapefruit juice. Higher doses lower the cholesterol more and increase adverse effects more, and only occasionally are shown to be more effective at reducing vascular disease. The most dramatic adverse effect of statins is a severe breakdown of muscles, called rhabdomyolysis, and that is more common in the elderly, those with underlying organ dysfunction and those who take medications to lower the triglyceride levels (fibrates.)

A recent article came out in the European Heart Journal, looking at long term followup of treatment with atorvastatin in a study of various medications for high blood pressure with or without cholesterol lowering drugs. The results were nearly impossible to understand, showing that people who were initially placed on atorvastatin who had high blood pressure did live longer, but primarily due to the fact that they were less likely to get pneumonia. Huh? In addition to that, after the two or so years that the study continued ( it was stopped early because the patients on atorvastatin had so many fewer heart attacks and strokes) nearly all of the patients in either treatment or control group were put on statins, so they were pretty much identical in all ways except for the first two years. As I read this, it would suggest that taking lipitor for 2 years, 11 years ago reduces your risk for pneumonia in subsequent years, which just doesn't make a reasonable amount of sense.

Bottom line: Lipitor is probably good for you if you have had angina or a heart attack and don't want it to happen again. It can cause a myriad of side effects, some of which can be pretty subtle but can significantly impact a person's life. If your cholesterol is just high, but your heart and vessels are fine, Lipitor (or other statins) might be very good for you, and might be bad for you, and it is kind of hard to know from the studies whether to take it. It is unlikely that Lipitor was invented by evil aliens, but if it was, they are really raking in the bucks.

Preventing Alzheimer's disease and sudden death--can it be this easy?...and other stories of disease prevention

2011-08-28T22:19:00.000-07:00

Reading through the Internal Medicine News today was surprisingly uplifting. This is a large format free journal that highlights studies presented in journals or in meetings around the world. This time the most interesting articles were about prevention of disease.

Deborah Barnes and her associates calculated, using recent reviews on the subject, that improvement in various health and lifestyle conditions could potentially avert millions of cases of Alzheimer's disease. These conditions, in order of importance, are physical inactivity, depression, smoking, hypertension, obesity, low educational attainment and diabetes. She calculates that half of the more than 36 million cases worldwide are at least partially due to these risk factors. This information is especially nice since all of these conditions are independently important and strongly impact a person's health and happiness in other ways.

Sudden death is usually due to a heart attack, though pulmonary embolus, ruptured aneurysms and major strokes are also culprits. It turns out that women who maintain a healthy weight, don't smoke, exercise regularly and eat a healthy diet have a 92% lower risk of sudden cardiac death than those who do none of these things. That's big! and if one combines this with the news about Alzheimer's disease, it sounds like good health habits might be a really good idea!

In addition to not dying of a heart attack and not getting Alzheimer's disease, it would be really nice not to get HIV. HIV and AIDS are now treatable as a chronic disease, and some of the misery suffered by those who are infected with it can be averted by regularly taking medications to kill the virus. Nevertheless, HIV infection is not fun. Safe sex, that is protection against contact with the body fluids of someone who is infected with HIV by either abstaining from contact or using condoms or other protective equipment is effective in preventing transmission. But safe sex is not always practical, as in the case of marriages or partnerships where only one member has the infection. It turns out that taking a regular daily dose of a combination HIV antiviral medication can reduce the incidence of infection of the non-infected partner by over 70% according to a study done in Kenya. The most effective preventive drug, Truvada, is not cheap and does have some significant side effects, which may limit the overall impact of this finding.

Preventing health catastrophes--what works?

2011-08-25T23:03:00.000-07:00

Today in the Journal of the American Medical Association David Jenkins MD and colleagues from Toronto, Ontario reported that certain dietary interventions really do help reduce cholesterol levels. Most patients believe, because we have told them, that improving their diets by eating less fat will significantly lower their cholesterol levels. According to a really well done study published in 1998, that is not true. Combining such a diet with exercise is helpful in reducing cholesterol, and probably also reduces many other bad health outcomes, such as diabetes, obesity and death. In Dr. Jenkins' study, however, patients were not told just to eat less fat, they were also instructed in what foods to add to their diets to reduce cholesterol. The study participants were instructed to eat a vegetarian diet and to add plant sterol containing margarine, soluble fiber (such as psyllium, oats or barley), soy protein products such as tofu and soy milk and peanuts or tree nuts. Simply being nagged to eat this way (2 sessions, total of 1 3/4 hours) lowered the cholesterol over 20 points (13%). The low fat diet, which was the control group, made almost no difference. Patients who actually followed the study diet had the best results, which is at it should be.

But having high cholesterol is hardly a health catastrophe. Heart attacks are catastrophes, and every year over a quarter of a million people die of heart attacks. We know that elevated cholesterol levels are a risk factor for heart attacks, but there has been no study that I can find that proves that lowering cholesterol levels by diet reduces heart attack. Perhaps it doesn't hurt, but even that is unclear. Cholesterol lowering drugs, such as the pharmacological blockbuster lipitor, definitely do lower cholesterol and lower risk of dying of a heart attack, but that may be due to any of a number of mechanisms, including lowering inflammation.

One of the most devastating catastrophes of aging is a bone fracture. As people age, bones become weaker and with relatively minimal trauma, such as with a low impact fall, can break. The most significant of these fractures is of the hip. Most hip fractures are fatal if untreated, and surgery to stabilize them is not a small thing. In the year following a hip fracture 15-20% of patients die, and many more require long nursing home stays.

People with osteoporosis are most likely to sustain hip fractures, and osteoporosis is increasingly common as our population ages. It is common to get a bone density study done after menopause to identify osteoporosis and physicians are often asked to prescribe medicine to strengthen bones when the bone density study shows that the risk of fracture is increased. Medicines such as fosamax (alendronate, now generic) can increase the bone density and reduce the risk of fractures, but all medicines for osteoporosis have side effects, from esophageal ulcers to unintended bone fractures and jaw bone death. The side effects are infrequent, but that is no consolation to the occasional patient who gets the side effect. Because the medicines for osteoporosis are hard to love, we physicians often recommend to patients with waning bone density that they start calcium and vitamin D supplementation. These are inexpensive and pretty much natural, but there is no evidence that I can find that they actually work to prevent fractures. A 1998 study in the New England Journal showed that supplementation with calcium 1000-1500 mg and vitamin D 400 IU daily slightly increased bone density, but did not reduce hip fractures. On the strength of that study, we physicians temporarily stopped recommending calcium and vitamin D, but we are back at it again, based only on some vaguely applicable studies of vitamin D alone in nursing home populations.

Of course, getting scientific proof of what works and what doesn't is closely attached to both funding and practicality. Drug trials can be performed in a double blind, placebo controlled manner, the most scientifically trustworthy design, whereas lifestyle and diet changes cannot be tested that way at all. It is very expensive to carry out a well designed trial of any sort, but big pharma has that kind of money, and can afford to spend it on science since the return on a positive study is very significant (Lipitor (atorvastatin) earned Pfizer 9 billion dollars in 2009).

What is a person to do? Should we as physicians stop giving health advice that is of dubious accuracy? Since people sometimes actually do listen to us and do what we recommend, should we work harder to produce some kind of guidelines for good health behaviors that will be easy to understand and of minimal complexity?

Fecal transplants: rethinking therapy for tummy troubles

2011-08-19T23:30:00.000-07:00

Since Alexander Fleming first discovered penicillin in 1928 and the first sulfonamide antibiotic was introduced in 1932, medical science has created countless chemicals that inhibit the growth of disease causing microbes. Dirty wounds that would have resulted in certain death prior to antibiotic therapy were treatable and curable. It must have been a very exciting time to be a doctor.

In my lifetime, the number of antibiotics available to use to treat infections has grown to the extent that, even with constant vigilance, I can't keep track of them all. Antibiotics are more often prescribed not for life threatening infections, but for treatment of symptoms such as sore throats, stuffy noses and inflamed bug bites for which those antibiotics are undoubtedly not effective, symptoms which if left untreated would resolve on their own. These prescribed antibiotics kill bacteria anywhere in the human body where the blood delivers them, hitting complex bacterial communities much as a bombing raid might hit our home towns. Appreciation for the beneficial roles of these communities, or microbiomes, is increasing in scientific and medical circles, but indiscriminate use of powerful antibiotics continues to be common practice.

Of the many problems associated with use of antibiotics, resistant bacteria is one of the most commonly recognized. In the hospital setting a common scenario is development of severe diarrhea following antibiotic use, often leading to prolonged hospital stays, nutritional compromise and sometimes death. The usual cause of this diarrhea is the bacterium Clostridium Difficile. At worst, this bacteria, which is resistant to many common antibiotics and common in the human gut, will cause diarrhea, nausea and vomiting, abdominal pain, fever and a raw intestinal lining that can even perforate, releasing stool into the sterile abdominal cavity. There are two antibiotics that can attack Clostridium Difficile, but even at their most effective they can still leave viable bacteria which can multiply again, causing recurrent or chronic infection.

For more than half a century physicians have recognized that, since C. Diff occurs after the healthy bacterial population in the gut is devastated by antibiotics, that restoration of the good bacteria might lead to a cure. In 1958 a physician reported using an enema of stool from a healthy donor to cure this disease. More recently we have attempted to treat persistent cases with "probiotics"--supplements consisting of bacteria like those in yogurt, and another, similar to one used in making fermented spirits, Saccharomyces Boulardii. These tricks have sometimes worked, though not, by any means, infallibly. It is tempting to try to treat a disease like C. Diff with a bacteria that smells good and is encased in a gel cap, one which is well defined and undeniably safe. Nevertheless, it makes much more sense that a persistent and pernicious pathogen would be vanquished by an army of cooperating bacterial species, no matter how smelly and undefined they are. Thus fecal transplantation has started to find its way into standard medical care.

In our small office my gastroenterology colleague was treating a very miserable elderly woman with recurrent and persistent C. Diff diarrhea. He had used all the appropriate antibiotics to treat it, all of the sweet smelling probiotics available, and still she cramped, she pooped, she had no appetite, she felt terrible. In fact, she was slowly dying. He recommended fecal transplant (also known as fecal flora reconstitution or fecal biotherapy.) She was game.

This is how it was done: The donor, usually a household or family member, donated the first morning bowel movement. The donor should be tested for parasites and blood diseases and is screened to make sure she or he has normal bowel habits. The recipient cleaned herself out by drinking the solution that we use prior to a colonoscopy, about a half a gallon of flavored polyethylene glycol solution. In a blender (which was subsequently thrown away) the BM was mixed with saline solution (not bacteriostatic) and then delivered in several portions as a retention enema. That's all.

Our patient was cured, just about immediately and so far completely. This is a very common result, according to the studies I have been reading.

Other techniques include instilling the solution by fiberoptic scope and by a plastic tube that goes through the nose and into the small intestine. There is no indication as to which technique works best.

At least one study also noted success in treating ulcerative colitis, a chronic inflammation of the bowel, with fecal transplant. It is far from standard treatment for this condition, however.

One of the most common bowel problems in my practice, leading to significant disability and work loss, is something called Irritable Bowel Syndrome (IBS). This condition causes no inflammation of the colon, just diarrhea and constipation, bloating, cramping and sometimes a sensation of incomplete emptying. Treatment of this condition usually involves avoiding foods that make it worse, bulking up the stool with fiber and occasionally taking medications that reduce bowel motility and cramping. Lately we have found that certain antibiotics sometimes reduce the associated bloating and discovered that the disease often follows a case of traveler's diarrhea, suggesting a bacterial cause. We have begun to treat irritable bowel with probiotic pills with some success. Is it not, perhaps, time to introduce healthy stool into patients with irritable bowel and look for cure rather than remediation?

Studies on obese humans and mice suggest that the bacteria in the gut is different than in their normal weight counterparts. In the case of mice, transplantation of bacteria from obese to normal weight animal results in weight gain. Are we, in fact, attributing fault regarding weight maintenance to human will power, when that fault at least partly belongs to our internal flora?

Another bacterial community that is vulnerable to decimation by antibiotic use is the vagina. It is very common for my patients to develop an itchy yeast infection after use of any of the powerful antibiotics that I prescribe for urinary tract and other infections. I treat these with oral or topical antifungal medications to wipe out the yeast, but it is not unusual for a patient to continue to itch on and off for weeks even after treatment. Often we recommend use of healthy bacteria, such as found in yogurt, to improve the flora. We usually have our patients eat the yogurt, but sometimes recommend they use it inside the vagina. It seems more likely that reconstitution of a whole community of bacterial flora by way of a transplant from a healthy vagina would work considerably better.

I sense at least 50% of my readers may be stifling a gag reflex at this point, assuming that they have made it this far. I sympathize, and yet it hardly seems reasonable that squeamishness should be an important decision rule in determining good therapy.

Certainly these thoughts and trends are part of a very important thought shift in organized medicine. They represent an element of respect for the complexity of the human organism and recognition of the limitations of our use of the chemicals of pharmacology to treat disease. The tremendously complex and interactive community that we know as our own bodies deserves to be recognized as we move in the direction of improving the quality of health care.

More reasons why Medicare costs are too high: hospice care is grossly overpriced

2011-08-02T22:00:00.000-07:00

Care of the dying is one of the most important jobs that a physician or nurse can have. Death, like birth, is a momentous and sacred transition, and good care can give peace and comfort to the patient as well as to his or her family and friends. The dying process is often painful and frightening and good, knowledgeable support can alleviate suffering for all involved.

Hospice care has evolved since its inception in the 1400s to embrace support of the dying both in designated facilities and in patients' own homes. Once a patient and his or her doctor have come to accept that a disease is terminal and that death is imminent (usually 6 months of expected life left) hospice care can usually be arranged to allow a patients last days or months to be as pain and anxiety free as possible, providing caregivers with the help and support they need. Hospice services usually include home visits by nurses and nurse's aids, medications for symptoms control, social worker visits, grief counseling, medical equipment needed for home care and coordination of treatment with the primary physician. Studies have shown that not only are patients in hospice care less expensive than ones with the same diagnosis who are treated with standard medical and curative care, but they often live longer.

Hospice providers are either non-profit organizations or, more commonly now, for profit agencies. Hospice care has gotten increasingly more accepted as physicians and patients have moved away from squeamishness about discussing and planning for death, and now costs Medicare over 12 billion dollars annually. That care, though, according to multiple studies, saves the American taxpayer lots of money compared to treating those patients with aggressive but ineffective treatment aimed at curing their disease.

It all sounds great. So what's the problem?

Hospice care is incredibly and unnecessarily expensive. How expensive? Really expensive.

A hospice patient of mine was alarmed when she saw a statement of what Medicare had paid for her hospice care and showed me her data. She had been placed on home hospice due to a chronic and progressive condition that appeared to be likely to result in her death. After several months of hospice, it became clear that she was, though very sick and incurable, stable and not yet dying. Hospice was discontinued, and she became a curious consumer. Hospice charges a monthly fee for their regular services plus hourly charges for visits by nurses, aids or therapists. Medicare paid her (for profit) agency between $7000 and $9000 monthly for this woman's hospice care. This consisted of a basal hospice fee of over $5000 plus visits by nurses charged at $191 per 15 minutes and nurses aides at $112 per 15 minutes. Nurse's aides usually make no more than $15/ hour in any job they can get, and nurses might make as much as $35/ hour if they are lucky.

This is just way too expensive. And it is positively ridiculous that Medicare pays this amount.

My patient also showed me an account of how much she spent on a private nurse after hospice was discontinued. For about the same amount of time that hospice had spent with her she had shelled out about $230 in a month.

The whole idea of hospice is that care aimed at symptom relief frees the doctor, patient and family of the need to engage in complex medical care that doesn't improve quality of life. This can be a creative and much less stressful type of medical care, with a very focused agenda. It involves very little expensive technology. It is, at its core, not very expensive. Where is all that money going? I'm not sure.

Cutting payments to hospice would lead to outraged wailing and tooth gnashing, and yet hospice astronomically overcharges for their services. We are very dependent on hospice availability at this point since the alternative (aggressive medical care at the end of life) is both more expensive and less effective.If threatened with a significant reduction in payments, many hospice providers would probably cease to do business, leaving us in a lurch.

This is yet another situation in which third party payment has resulted in costs far beyond what a reasonably prudent consumer would agree to pay. Awareness of the problem by physicians and patients can be powerful, but the very fact that such ridiculous excess is occurring so blatantly shows that something is very wrong with how Medicare and other insurance companies reimburse for services, undoubtedly resulting in many billions of dollars of true waste.

I am truly thankful for the kind and compassionate care that various hospice organizations have provided my patients over the years, and I would hate to see this service go away. The whole field of palliative medicine has made death just a little bit easier and has brought compassion and dignity to countless families. With costs as high as these, however, hospice may find that it prices itself right out of our nation's ability to pay.

Health Care Costs are Coming Down!

2011-07-24T18:46:00.000-07:00

It sounds like a nursery rhyme, but it's actually true.

Avery Johnson of the Wall Street Journal reported on an investor conference of Goldman Sachs in June of this year, in which major insurers discussed an unprecedented downward trend in medical spending. This has led to increased profits for insurance companies, but uneasiness in the many industries that live off of the abundance of excessive medical costs.

Specifically, hospital income is down 2-15%, costs associated with doctor visits are down 7%, and though patients are visiting quick care type providers more often, they are less likely to fill the prescriptions they receive at those visits. Simply put, people are going to the doctor less, they are spending less time and less money in the hospital and are taking less medications.

Humana reported and increase in profits of 30% and Aetna 42% since the patients they are insuring are costing them less money despite the fact that they raised premiums quite a bit last year. Eventually these profits will be limited by the provisions of the health care bill, so they will probably lead to reductions in health insurance premiums, but not this year.

The articles I read reported debate about whether the reduction in health care spending was just due to the economic downturn and was likely to end with a rebound as the economy recovers, but the magnitude of the decrease suggested something more permanent. Some data indicates that patients are considering costs more often when deciding on medical options and are looking at alternatives to standard medical care. Substantially more people have health plans that include very high deductible costs which fuels these considerations.

It will be very interesting to see if this voluntary reduction in health care spending can be correlated to a change in overall health. The patients who go to the minute clinics with their colds and flu and are prescribed antibiotics which they do not actually take may be well served by their "noncompliance". It seems to me that whenever a patient goes to a clinic like this with a cough or a sniffle they leave with an antibiotic, and if they take that antibiotic it is not uncommon for them to get some sort of side effect. Antibiotics are really only useful for a small subset of coughs, those due to pneumonia or to exacerbations of chronic lung disease, sometimes they help with sinus infections, and they are never useful in viral infections.

It seems most likely that this trend in health care spending is due to the fact that patients and doctors are starting to consider costs as part of what is relevant in making medical decisions. It seems like the fact of uncontrollable medical costs continuing to spiral upward is not a fact at all, but simply one of a number of possible futures. Decisions we make as providers and consumers are already having a significant impact on spending, and health care is in the process of reforming itself (though it definitely still needs lots of help.) Certainly widely publicized debate about the subject has influenced behavior. Although, or because, providers and consumers are still so confused about the provisions of the health care reform bill, they are changing their what they do in such a way that costs are already beginning to come down.

An article in the American Medical News reported on a few studies presented at the June meeting of the American Society of Clinical Oncology that looked at the financial impact on patients of treating their cancers. It is not uncommon for patients whose cancers do respond to chemotherapy to end of bankrupt due to costs. The first really effective drug to treat advanced melanoma, Yervoy, will cost $120,000 for 4 doses. Other common newish chemotherapy drugs are similarly expensive. Although insurance covers some of these costs, copays are significant. Many patients are simply not willing to bankrupt themselves or their families for the chance of a longer life. Studies such as these were not something I saw even a few years ago, and data like this certainly helps inform discussions of how to make medical decisions in a world where resources are limited.

High blood pressure: who actually has it?

2011-07-12T23:05:00.000-07:00

Hypertension is defined as the abnormal elevation of the pressure of blood within the arteries as measured most often by a blood pressure cuff. About 1 in 3 Americans has hypertension (which is the same thing as high blood pressure and has almost nothing to do with stress or anxiety.) When I finished medical school about 25 years ago, hypertension was diagnosed in an adult when the blood pressure was above 140/90 mm of mercury. In the last several years, since mortality pretty much just increases with increasing blood pressure, lower levels of blood pressure have been identified as being abnormal. Now a person has prehypertension if their systolic (top number) blood pressure is between 120 and 139 or if their diastolic (bottom number) blood pressure is between 80 and 89.

High blood pressure is a big deal because it increases a person's risk for stroke, heart attack and kidney failure. It is also mostly completely silent, causing no discomfort except at very high levels. The only way to identify hypertension is through having the blood pressure checked, usually at a doctor's office.

In the June 21 issue of the Annals of Internal Medicine, Dr. Benjamin Powers and colleagues from the VA medical center in Durham, North Carolina, compared blood pressure measurements in clinics, by researchers and by patients in their homes to see how we actually diagnose and treat that most common of diseases. What they found has major implications for most patients who have been told they have high blood pressure, and for all of us who are interested in providing rational and appropriate care.

All studies that look at the treatment of blood pressures are supposed to use a standard method of measuring it. The patient should be sitting down, not speaking, with back supported, feet flat on the floor, after 5 minutes of rest. If a person has a blood pressure over 139/89 when measured in this way, on more than one occasion, that person can be diagnosed with hypertension. Unfortunately blood pressure is seldom measured this way in actual practice. I think that most people who have ever had a blood pressure measurement done have experienced at least one if not many deviations from this protocol. We often measure blood pressure on the fly, right after a patient has sat down, while interviewing them, sometimes when they are sitting on the exam table with their feet dangling and back un-supported. We reassure ourselves that it doesn't really matter, but it actually does. The article shows that blood pressures taken by patients, by doctors' offices and by research personnel (who do it properly) do not agree. On average, clinic blood pressures are higher than home measurements and those are higher than research measurements. Measuring the blood pressure several times at the office can significantly help improve the accuracy of the diagnosis, and using 5 or 6 separate measurements provides the best results.

Another statistic that is interesting from this study is that, using doctor's office blood pressure measurements, only 28% of patients are found to have good blood pressure control. If we use the patient's own blood pressure measurements from their home machines, 47% have good blood pressure control, and if research personnel do the measurements, using proper technique, 68% of patients are in good control. To me this sounds like, because of shoddy blood pressure measurements 40% of our patients are mistakenly told that their blood pressure is too high, which would lead to expensive medication prescriptions and followup appointments.

Reviewing various sources on the subject, it appears that the condition hypertension costs the US nearly 80 billion dollars yearly of which maybe 25-30 billion dollars goes to actually treating hypertension (medications and office calls). The rest of this cost is presumably related to treating the conditions that high blood pressure causes. Appropriate allocation of resources to patients who actually have hypertension is supremely important. Repeated visits to treat uncontrolled hypertension, in my experience, leads to very high medication costs, higher incidence of medication side effects and, of course, frustration for both doctor and patient. If blood pressure control is being determined by significantly inaccurate technique, some simple changes could potentially make a significant impact both in dollars spent and quality of outcome.

So, you may ask, why not just do it right, all the time? A valid question. Not a year passes without some concentrated attempt by organizations such as the American Heart Association to re-educate us in the proper measurement of blood pressure. Still, the constraints of being in a hurry (I think that trumps ignorance in its importance) continues to result in blood pressure measurements being done badly. The consequences of this are moderately important to each individual diagnosed with hypertension, and have a profound effect at the level of our whole population.

Antibiotics for appendicitis, heparin for burns and other stories of wonder

2011-06-27T21:47:00.000-07:00

In the recent batch of throw away journals, several articles reported on findings that are at least moderately exciting.

The first was from the annual meeting of the Central Surgical Association in Detroit. An analysis of several studies pointed out that many cases of CT scan proven appendicitis can be effectively treated with intravenous antibiotics. In the past, when I was trained in medicine and surgery, appendicitis was diagnosed entirely on clinical grounds. Exquisite tenderness in the right lower quadrant, fever, elevated white blood cell count and a story of diffuse abdominal pain gradually focusing on the lower abdomen were sufficient evidence to operate on a suspected acute appendicitis. Cases without all of these findings were also operated on, and removing a normal appendix was considered part of the cost of preventing a catastrophic appendix rupture with the associated spillage of fecal matter into the sterile abdominal space. Now classic cases of appendicitis as described here will usually be corroborated with an abdominal and pelvic CT scan which will show a characteristic swelling of the appendix. When appendicitis is treated with antibiotics, 20% of patients can avoid an appendectomy and will be able to walk home without an incision in their belly and without the risk of surgical and anesthesia complications.

The British Medical Journal online is said to have reported on a New Zealand study showing that in a randomized controlled trial of nearly 40,000 patients, women who took a somewhat low dose of calcium and vitamin D, 1 gram and 400 IU, had about 1.2 times the risk of women not taking calcium and vitamin D of having heart attacks and strokes. Other studies show similar findings for calcium alone. To truly evaluate the risks and benefits of calcium, one would need to know if calcium and vitamin D supplements in normal women actually prevent the condition they are prescribed for, that is osteoporotic fractures. When last I heard, proof of a positive effect of calcium on bone strength was lacking and vitamin D supplementation was only definitely good for fracture prevention in the frail elderly. I am not entirely sure what to do with this information, other than inform my patients of the depth of our ignorance regarding these supplements.

At the international conference of the American Thoracic Society, researchers reported that daily treatment with the antibiotic azithromycin could postpone exacerbations of chronic lung disease for nearly 100 days compared to patients not treated with the antibiotic. Azithromycin, because of how well tolerated it is and how it can be given in a very short course due to its persistence in the body, is one of the most overused antibiotics in my experience. It is pretty much good for what ails you: hang nails, mosquito bites, colds and flu. It is even generic. Using it daily on patients with chronic lung disease will undoubtedly cause an increased resistance of community bacteria to the drug, making it useless for others who might need it. Clearly this is an intervention that needs to be chosen after much consideration, and for patients who really have very little lung reserve.

A rheumatological meeting at New York University reported that treatment of gout with medications that reduce uric acid levels can decrease heart related mortality by nearly 50%. Patients with gout have elevated levels of uric acid in their blood streams, related to diet, genetics, kidney function and medications they take. Many patients have elevated uric acid levels without getting gout (a very painful inflammation of joints and soft tissues, especially in the legs.) These patients also will benefit from lowering the uric acid levels. The medication used most commonly to lower uric acid is allopurinol. It is very inexpensive and sometimes causes an allergic rash or hair loss. In general it is very well tolerated and very affordable. There are many medications that can control gout symptoms but only the medications that reduce uric acid levels are helpful to the heart. Allopurinol and it's new cousin Febuxostat work, as do the two ancient gout drugs probenicid and sulfinpyrazone which make a person eliminate uric acid in the urine. This study will help me counsel patients on what medicine to take to prevent gout.

The proceedings of the National Academy of Science apparently reported on a slight reduction of the effectiveness of SSRI antidepressants such as Prozac (fluoxetine) in patients (and mice) treated with certain medications for pain, specifically NSAIDs such as ibuprofen and naproxen. The effect is small, but certainly worth thinking about if a patient doesn't respond to antidepressant medications. Of course, if they give up their effective pain medication, which may reduce their exercise, depression may rear its head in another way.

The British Medical Journal reported in May that using beta blocker medications along with asthma inhaler medications for chronic obstructive lung disease actually improves survival. I had always been convinced that use of a beta blocker in a patient who wheezed was a very bad idea and would reduce the effectiveness of a drug that stimulated beta receptors, such as albuterol. In fact I would often scoff at the silliness of doctors who would have their patients on both beta blockers and beta stimulators. I'm thinking now that I was probably wrong.

The last and most fascinating drug story came to me in the form of a high school friend whose father, a family practitioner, I knew from childhood. She visited me unexpectedly last weekend and told me his story and showed me his website. He, Michael Saliba MD, worked in La Jolla and did some research early on at UC San Diego medical school on treatment of burns. He found that a common and inexpensive medication that we use for treating blood clots, heparin, was a very powerful stimulator of skin healing in burned or otherwise denuded skin. He was able to try this on humans and over the years has successfully treated people with quite severe burns with heparin. He applies the solution by dripping it on a wound in the case of small wounds, and intravenously and as a subcutaneous injection of high doses in much more significant burns. He found that not only did it dramatically speed healing but it also nearly completely relieved pain, and patients often healed without much scarring. Most of the centers which use heparin are overseas, however, and the routine has never caught on in the US. Although there have been more studies reported, some showing dramatic successes and reductions in associated costs, there are none of the large multi-center studies that usually herald a major change in therapeutics. Some explanations include the fact that heparin has been a generic medication for so long that it doesn't financially benefit anyone to study it, that high doses of heparin worry physicians due to perceived risk of major bleeding (which actually only happens if there are bleeding injuries in the first place) and possibly due the fact that our standard treatments of very large burns is very big business, supporting all kinds of medical industry. Or he could just be making it up. Having known Dr. Saliba for as many years as I have, his overall kindness and trustworthiness are strong enough that I doubt that his claims are exaggerated. I think I will try it for the next burn wound I see. Besides being a very inexpensive treatment, what excites me most of all is the potential to treat burn pain which is so difficult to manage with oral medications.

Accountable Care Organizations--some perils and pitfalls

2011-06-08T22:30:00.000-07:00

It is ever more widely accepted that fee for service medicine, that is payment for individual services that medical professionals provide, by patients or by insurers, is a bad idea. If a physician is paid to deliver a specific service, such as seeing a patient in the office, removing his or her gallbladder or doing a colonoscopy, the physician will perform more of these services, regardless of whether this improves the health of the patient. Ethically a doctor may make appropriate choices, but financially the reward will be for quantity of services not quality of care. If a health care provider is paid to take care of a patient, a flat fee per patient per year for instance, the incentive will be to keep that patient as healthy as possible with as little medical intervention as possible and to prevent costly disease. This is known as "capitation" (literally paying by the head.)

Capitation has been tried and used in many situations over many years in medicine. Staff model health care cooperatives such as Kaiser and Group Health operate this way. Many states pay flat fees to providers to serve their medicaid populations. Outcomes are often better because this system focuses on continuity of care with members assigned to specific doctors, and usually involves better coordination of aspects of care by the different providers involved. It sometimes irritates patients because choices of specialists and medications are often limited due to the staff model and to money saving drug formularies. In cooperatives, a governing board which includes patients help make decisions about what kinds of care are provided, which makes them somewhat more responsive to consumers' needs.

The present model (outlined in the Affordable Care Act) that attempts to get away from fee for service medicine is called the Accountable Care Organization (ACO). A group of physicians, often in cahoots with a hospital, can contract with medicare to provide service to at least 5000 medicare patients, and if they can provide that care for cheaper than benchmarks, while documenting good quality as measured by various things that organized medicine thinks is important such as lab test numbers and hospital admissions, they can have a share of the saved loot. There are various reasons why this is not a great solution. First of all, the creation of accountable care organizations is driving a big push by hospitals to employ physicians, which may make medicine more corporate, placing yet another entity between the patient and the provider. If a physician is employed, the rules of practice will likely be defined by the employer, and if that employer is interested entirely in saving money, convenience and the human touch may well be lost. Also, these much larger organizations may, by controlling more of the care that is delivered, have enough power to actually push costs up by monopolizing care.

Another problem with the present model of an ACO is that it would not end fee for service at all, and so the administrative hassles involved in making lists of diagnoses for each patient and matching them up with fees for units of service will continue to eat up our time. More non-patient time will be eaten by the documentation of quality. It is not entirely bad to be required to demonstrate that our care works, but the devil is in the details, and getting cholesterol numbers just right may not be the thing that my patients actually value.

Finally, in my personal world, ACOs are impractical because a community the size of mine, around 20,000 people, is too small to have 5000 medicare beneficiaries as is required by the Affordable Care Act. We could potentially hook up with other communities, but having meetings and communicating would be a nightmare, given the density of population around here.

I do think that physicians need to be more involved in providing care for patients that contributes to their actual health and happiness instead of simply providing units of service. I think that a system that rewards good care and encourages creative ways of delivering it are part of a successful future for medicine. It is vitally important in all of this that we continue to care for our patients and remain committed to the give and take relationship that allows us to share our knowledge while respecting what our patients value. Having a third party, an insurance company, pay for our services already negatively affects this intimate partnership. It is my hope that in reforming our present payment system we do not introduce yet another financially motivated entity into the exam room.

How to get more gifted physicians to practice primary care

2011-06-02T18:52:00.000-07:00

It is entirely clear that too few medical graduates go into primary care. Although the number of family physicians is increasing modestly, there are very few internal medicine residents becoming primary care doctors. This year there will be only about 200 new internal medicine doctors entering the workforce from training programs, which will not even begin to cover the attrition of older and more efficient physicians, and due to improvements in access with the affordable care act, demand will be increasing significantly. The main reason that very few physicians are choosing primary care is that specialty fields are just about as rewarding personally and way more rewarding financially.

Insurance companies in our present, primarily fee for service, payment system, pay generously for operations and procedures, but much less for complex interactions such as counseling patients on their multiple medical problems, medications, and managing their many diseases. A cataract operation is reimbursed at around $1500 or more, and an ophthalmologist can perform one of these in less than an hour. A similar hour of seeing patients will net a physician a small fraction of that amount of money, and will require many more decisions and neuron firings. Many other procedures have similar high reimbursement for very low amounts of work. If a physician specializes in a field that involves many procedures, he or she can make truly absurd amounts of money if there are sufficient numbers of patients who need that procedure.

Because of the shortage of primary care doctors, more and more people are getting their primary care from nurse practitioners and physician's assistants, who have many fewer years of education than a physician. These providers are paid less than physicians and are more plentiful. Many of them are very competent, but patients often prefer an MD over a PA because the MD has a greater depth of knowledge. A primary care visit is often a combination of counseling about psychological issues, medications and interactions, review of tests, recommendations about prevention and careful examination (at its best). MDs can be very good at this. Midlevel practitioners are often quicker, having been trained to treat urgent problems more than chronic ones.

Training to be a primary care physician requires at least 7 years after completing a bachelors or higher level college degree. The first year is spent learning basic science and physiology, the second involves absorbing huge amounts of information about human beings in health and disease. The third and fourth years bring the student in direct contact with patients, providing supervised clinical care along with classes and individual teaching by practicing physicians and academics. After these 4 years we have an MD degree, and must pass a licensing exam that assures a certain level of competence in all fields of medicine. At this point we can still choose to become surgeons, radiologists, pathologists or go on to academic medicine or research. Those of us who intend to be primary care docs then spend at least 3 years in residency, taking care of patients under the supervision of more experienced physicians, with an increasing level of independence. When we finish these residency years we are broadly competent in taking care of most of what can go wrong with a human, with fresh and extensive knowledge of psychiatry, critical care, well patient care and the vast variety of other illnesses we have been exposed to. After those residency years we have the opportunity to take another year or more of specialty training in fields such as cardiology, oncology, infections disease or rheumatology. Most physicians who specialize limit their practices to specific diseases and no longer do general medicine.

Nurse practitioners and physicians assistants must complete 2-3 years of training after getting their undergraduate degrees and in most states are then certified to practice independently. Although they are often gifted and become increasingly capable with years of practice, they do start out with considerably less training than physicians and the programs that train them are significantly less competitive.

So what would a midlevel practitioner be really excellent at doing? In what kind of a situation would a provider with less extensive experience and education really shine? Procedures. A midlevel such as a nurse practitioner or physicians assistant could learn to do an excellent cataract extraction or colonoscopy. Advanced level nurses already act as surgical assistants and have been providing anesthesia services at a high level for longer than MDs have done. In developing countries with less medical regulations, it is often the janitors or former patients who learn to do operations and act as surgeons when the foreign trained doctors are not available. I have read that some of the most skillful surgeons for vaginal fistulas, a very delicate and specialized condition of women who have had disastrous labors, are lay people.

What else would midlevels really excel at? Already much of diabetes care is delivered by nurse practitioners who limit themselves to issues related to that disease. They do an excellent job, often better than MDs. Specific disease states, as are now managed by subspecialists, would be perfect for nurse practitioners and PAs. In fact, this is already starting to gain momentum.

How would shifting procedural work to midlevel providers affect the health care equation? If less well paid providers did this work market forces would drive down costs, which would make procedure rich specialties less desirable. Health care costs would also go down, and if cognitive specialties such as primary care were even somewhat better reimbursed it would increase the number of talented folks choosing those careers.

A recent article in the New England Journal of Medicine obliquely addressed this question. Here is the link:

http://www.nejm.org/doi/full/10.1056/NEJMoa1009370

In this article authors looked at the success of treatment of hepatitis C by specialists vs primary care doctors after an online course in treating this common and deadly disease. Primary care providers were slightly more successful than the gastroenterology clinic which trained them in curing the disease. This does, of course, involve MD providers in both cases, but gives very strong support for the idea that specialization can be taught effectively and quickly.

A move in this direction will be very unpopular among just those who are most needed to make it work, the MDs who make their livings doing procedures. These folks have years of practical experience and have skills that are not available in books or videos. Excellent surgeons will always be necessary and appreciated. A supremely skilled surgeon is an artist and deserves money and acclaim. Wise subspecialists will always be needed and appreciated in taking care of patients with diseases that are rare or so complicated that primary care physicians are just not enough. But we are now grossly out of balance, with a truly inadequate number of primary care physicians to take care our our growing needs, and appropriate use of midlevels could be a solution to the problem.

How I Spent My Day, most of it good, some of it stupid (E and M codes)

2011-05-25T22:51:00.000-07:00

Today started early because I was being the hospitalist as well as the stress test doctor as well as my usual identity as primary care physician. A hospitalist is a doctor who takes care of all of the patients in a hospital who have no other doctor or whose doctor doesn't take care of patients in a hospital. It is a fine job, as it is practiced in many larger communities, though it limits the doctor's ability to make long term connections with patients, who usually see someone else when they are not confined to a hospital. People who take hospitalist jobs work shifts, make a fixed salary and get lots of time off. In our small town, the hospitalist is my long suffering partner, nearly all of the time, but I and my other internal medicine colleagues spell her evenings and weekends and occasional vacations. We all squeeze our hospital work into a day that also includes outpatient primary care medicine.

As the hospitalist I had 6 patients to see before clinic started at 10, only 2 of them really critically ill, and because this is my week for doing stress tests, I had two other people to supervise while we used various methods to stress their hearts to see if they had coronary artery disease. The stress tests are a great joy because I get to meet new people and hear their stories and give them health advice while they are open to it. While they are walking or being injected there is nothing else I need to be doing, no computers to interact with, at least not in a distracting way, and no distractions. There is plenty of time to find out who they are and maybe help them make a slight detour if their lifestyle and habits are heading them in a deadly direction.

After nearly 25 years of medical practice, most things I do are rewarding. There are exceptions, however. Most exceptions fall into the category of things I can't do well. If there is something I don't know about or physically am not skilled enough to do, I can find a colleague to help. The most difficult situation, though, is when it is necessary to be in two places at the same time, or do two (or three) things in an inadequate amount of time. When situations like this arise, I begin to be annoyed by inefficient processes.

The New England Journal of Medicine published an article this week about one of the stupid processes upon which we physicians, those of us involved in fee for service medicine, waste our time.

here is the link:
http://healthpolicyandreform.nejm.org/?p=14489#more-14489

When I see my patients in the hospital, I just estimate the time and complexity of my services and bill accordingly. When I do stress tests, I am paid by the hour. When I see patients in the office I must calculate their bill based on Evaluation and Management Codes, introduced for the first time in 1991. These codes are an attempt to calculate the value of a medical service based on various pieces of information that can be documented in a patient's chart. If I document a very complete history and include a physical exam of several parts of the patient's body that is exhaustive, I can bill a 99214, which will pay me substantially more than a 99213 which still requires quite a bit of documentation. If I do everything imaginable in the appointment and document that, I can bill a 99215. This is the king of the outpatient bills and pays the most money. If I document that I spent an hour talking to the patient, I can legally bill a 99215, but if I work really fast and ask a whole bunch of questions and poke and prod every part of my patient and that patient is pretty complicated, I could potentially get 2, 3 or even 4 99215's in an hour. But by law if I bill a 99215 and I don't document that I did all of the little things I was supposed to to qualify for a 99215, I can be heavily fined or even arrested. (Legal sanctions apply only to Medicare and Medicaid billing, but E and M coding is used pretty much universally by all insurers.)

So today, like every day, despite the fact that today was plenty crowded with people who needed my attention, I spent a significant amount of precious time making sure that I documented (typed up, clicked on) enough elements for my outpatients that my billing would stand up to scrutiny should I be audited. My electronic medical record is built to help me with my E and M coding, but because it is so geared to coding, it is not nearly as good at concisely expressing what I did with my patient. I can review the patient's family history and social situation, but if I don't include the verbiage, which may be identical to the verbiage I documented last week, my documentation will be inadequate to bill for the complex and time consuming interaction and I will need to charge less than the appointment was worth. The time I spend polishing my documentation is time that I can't see sick patients. It also, more insidiously, affects the way in which I care for my patients and what my brain is doing when I am with them. It is vital for the survival of my office that I make enough money to support my nurses and receptionists, pay my rent and eventually support my family. So I, like all other fee for service physicians, play the E and M game. I am mostly unable to get payment for any of the rest of the work that I do, such as telephone management or written communications, so E and M coding of my face to face patient interactions pays for everything else I do.

When the various codes were introduced in the early 90s, many of us objected to the changes, but now we are so accustomed to spending our time and brain cells to categorize our work in this way that very few people even realize what an impact this has on our quality of service. Robert Berenson MD, Peter Basch MD and Amanda Sussex MPH who wrote the New England Journal article are the first to publicly complain about this system for years. Improvements in billing including streamlining the coding has been suggested, but instead it will soon be getting even more complex. Truly the best solution to the foul and tangled web of medical billing will be significant payment reform. Calls for the end of fee for service medicine have been increasingly common, and as far as I'm concerned, it can't happen soon enough.

How death panels can save your life and other stories

2011-05-18T22:49:00.000-07:00

The Annals of Internal Medicine occasionally reviews the articles and studies of note in a particular field of internal medicine for those of us who don't read all of the specialty journals. This month there was an update in pulmonary and critical care medicine, the internal medicine specialty that is most intimately involved with caring for the very ill and those people who are at the ends of their lives. Nestled among articles on diagnosis of tuberculosis and novel treatments for non-small cell lung cancer is one about palliative care, that is medical interventions intended to make people more comfortable as they die.

This article, published in the New England Journal of Medicine by Dr. J.S. Temel and colleagues from the Massachusetts General Hospital in Boston, looks at quality and length of life in patients with recently diagnosed incurable lung cancer, cancers that have spread metastatically beyond the lung tissue. These patients cannot expect to be cured of their cancers, but will be offered many treatments intended to lengthen their lives and shrink their tumors. About half of the patients were offered visits early in their treatment with the palliative care team, to discuss what kind of treatment they wanted at the end of their life, including resuscitation and life support, but also pain and other symptom control. The other group received standard treatment, which might include palliative care, but usually not until life prolonging therapy was found to be ineffective. The patients assigned to early palliative care consultation received less intensive treatments as they were dying, but they also had a significantly better quality of life and they lived longer.

An article like this doesn't explore the individual stories of the people who were involved, but I'm thinking those stories would be pretty interesting. Without those stories, one can only speculate what made the early palliative care group happier and healthier. My speculations would include that it was comforting to patients to know that they would be well taken care of and their suffering would be relieved when it was their time to die. Other factors might include family members being reassured by open conversations about the end of life, leading to better care at home and more contact with doctors who are good listeners and take the time to really discuss the patient's and family's concerns.

It is also interesting to note that the group with early palliative care, though receiving less intensive medical interventions at the end of life, lived longer than those with more intensive interventions. Intensive care was not "rationed" as frightened legislators might think, but rather used appropriately for the individual.

The whole discussion of death panels sort of escaped me when it came around the first time and when it has recurrently resurfaced. End of life discussions have always been a part of practicing good medicine, and it would be nice to be paid for them specifically so that more physicians would take the time to do them properly. A panel of physicians would not be particularly good at talking to people about death and so a death panel, even if it weren't just a figment of a paranoid imagination, would be terribly inefficient. One of my patients, a 90 year old woman, expressed fear of death panels several months ago, and after explaining that I wasn't sure where that idea had sprung from, we had a good, simple and productive talk about what kind of therapy was available to her should her heart stop or her other functions cease to be, and we were able to document exactly what she would want should she not be able to express her wishes.

As doctors who frequently admit patients who normally see other doctors to the hospital, my partner and I are often on the receiving end of the problem of inadequate discussions of end of life wishes. Very ill or dying patients will be admitted to the hospital, with one of us as their doctor, and have never discussed with anyone what kind of care they would want. They are often too sick by that time to talk about it or think about it, and even if they were capable, they don't know me or my partner from Adam, and reasonably don't have the level of trust necessary to allow us to help them make a good decision. This leads to heartache and wasted effort.

So what I see as the take home message of this New England Journal article is that discussions of end of life preferences including life support but also ways to receive comfort do not need to be depressing, but can be affirmations of life's value and our own self determination. When a doctor opens up this area for a person and his or her family to talk about, fears can be allayed and options can be explored. Death is just about always difficult in some way or another, but there are many ways to handle it that help to maintain our love and humanity.

My TED Talk

2011-05-16T23:15:00.000-07:00

The Technology, Education and Design group was founded in 1984 in Monterey, California, to promote ideas that primarily related to information systems. Since that time, the focus has expanded and now includes subjects of global relevance as expressed in their mission statement: ..."We believe passionately in the power of ideas to change attitudes, lives and ultimately, the world. So we're building here a clearinghouse that offers free knowledge and inspiration from the world's most inspired thinkers, and also a community of curious souls to engage with ideas and each other."

TED talks have been criticized as being elitist and as reducing scientists and scholars to circus performers, but having watched several of them, I think that the discipline of having to express ones most important ideas in 18 minutes in a format that can be understood by just about everyone is a great idea. As far as elitist, I suppose that probably applies, since it is unlikely that anyone who is not well spoken and at least moderately well known will have the opportunity to speak. I, for instance, will not be invited. Which is why I will write my TED talk up on my blog rather than waiting for a phone call from whoever it is who telephones those who are worthy. There are TEDMED talks as well, which are about my field, but all of those folks are in some way hugely famous having won prizes, written books or earned honorary degrees. They talk about fascinating subjects, but so far I don't see anybody writing about whyamericanhealthcareissoexpensive.

A TED talk is kind of like a super-slow motion elevator speech. It involves both the idea to be explained and a mini-biography of the person with the idea, as a way of giving the idea a human setting. In that way, a TED talk is different from a church sermon and different from a college lecture. Here goes:

Half my life ago I became interested in practicing medicine. I came from a relatively well educated family, but not a medical one. My mother had painfully limited her choices by never finishing college. For me, medicine offered the opportunity to nurture while being financially and in many other ways independent, after paying the reasonable price of several years of indentured servitude. Besides the requirement for independence, my family had given me a powerful message of the value of frugality. As I moved further into my training in medicine I was frequently troubled by what looked like waste. I was trained at the Johns Hopkins School of Medicine, one of the most well respected medical schools in the world, so I withheld judgement about what seemed to be excessive use of testing and medications. I entered practice over 20 years ago, and saw a more haphazard use of technology, and experienced the system of cooperative managed care as practiced in my first job as a general internist at Group Health in Everett, Washington. There, certain expensive resources were jealously guarded, but other ones were used even when inappropriate. When I moved away to a private practice setting, I learned how efficient I could be by getting to know my patients well and discussing options with them for evaluation and treatment. As the years went on, there were even decision trees to help decide on the best alternatives, though those did not always represent my patients' needs.

Frugality was offended, however, when my patients were referred to specialists or ended up in the emergency department due to sudden changes in their health. In these places tests were ordered without a second thought and medications prescribed without conversations about costs or alternatives. One day after a CT scan ordered by another physician showed a confusing but not very concerning finding on a patient who had far too many medical tests due to her inability to express herself well, the radiologist and I, while speaking on the phone together, simultaneously said "I could lower healthcare costs 30% tomorrow." We had simultaneously become so frustrated with the way medicine was practiced that it was no longer a discussion about this particular patient, but of the whole way tests, procedures and medications were ordered.

Not long after that, in the heat of debates about what to do with an American health care system that fails to offer even marginal care to millions of low and middle income citizens, I began to do rough math to determine exactly how much money was being wasted on unhelpful, unnecessary and potentially harmful testing and treatment on a regular basis. By practicing medicine as a primary care physician often does, it is more than possible to waste 10s of thousands of dollars a day, without even considering the overuse of more expensive procedures such as surgeries and prescription of medical contraptions of dubious utility that goes on outside of my areas of expertise.

This overuse of unnecessary medical interventions is primarily due to the long standing fee for service system in much of medical practice, in which a physician is paid not for keeping a person healthy, but often just the opposite, seeing them or doing things to them. Humans in general want to be healthy, happy and live a long time, then be allowed to die in peace and comfort. So much of medicine is not in any way furthering those aims. In addition to fee for service, third party payment (insurance policies paying for medical care) protects physicians from free market forces, since patients don't have any direct interest in the cost of their medical care and insurance companies can and do simply pass on outlandish costs to insurance consumers as premiums. A CT scan, for instance, costs much more in the US than in other countries and is used much more frequently, at a cost of 10s of thousands of lives every year from radiation exposure and with no proven benefit in many cases.

The fear of being sued for malpractice is more than a small influence on these issues, though lack of incentive to reduce costs is much more important. Certainly physicians are sued if a cancer is discovered at an advanced stage when a well timed CT scan or other procedure could have saved a life, however much of the drive to sue for malpractice is based on becoming impoverished by medical costs and due to dissatisfaction with physicians, all of which can be traced to an inefficient and non-patient centered approach to medical care.

The third party system is also a fierce temptation to commit fraud. Complex billing schemes make a patient's bill nearly impossible to interpret, and so it is rare for a patient to question a bill in any way that is effective. An insurance company paying the bill may have an incentive to make sure billing is honest, but the insurance company employee investigating a bill has no actual knowledge of what service was performed and a very difficult time tracing whether such a service was appropriate. I'm not sure whether there is a theorem that states that where fraud is possible it is occurring at the rate that is just slightly below the system's ability to detect it, but there should be. Huge amounts of money are inevitably being outright wasted due to fraudulent billing.

So what is the simple solution to all of this?

Physicians could simply start thinking of cost as an issue when prescribing testing, procedures, medications or medical devices. This should not be the only consideration, but in a world in which resources are limited, it is absolutely necessary that cost be part of the discussion. These discussions should be between the physicians and their patients, taking into account all of the issues. Patients also need to begin to take some responsibility for health care costs, participating in shared decision making in a well considered way.

The third party fee for service system of payment for medical care must go. Without direct connection of costs to good outcomes, those costs will continue to rise without any appropriate value. A physician who is paid a set amount to keep a patient healthy will have much more incentive to practice cost-effective care than one with a blank check and no other motivation to do well than his or her own ethical belief system. A system that combines the successes of staff model health care cooperatives with the personal touch and intimate contract of concierge medicine can provide those incentives at a fraction of the cost of providing the inadequate care we have now. Eliminating fee for service medicine will help push physicians to use all of the networking technology available to communicate with patients in a way that is most convenient and effective for both parties.

The system of civil suits for malpractice needs to be significantly changed. Presently malpractice suits take years to be resolved, end up with angry patients and angry physicians, ruin lives and careers and often provide no compensation for an injured party. Suits contribute to physician burnout and attrition, which further worsens access to primary care. A good system would compensate patients quickly for injury and target hospitals and responsible physicians for improvement of knowledge, attitudes and systems to prevent further injury. No fault systems have been effective elsewhere, and mediation has already had a big impact on compensation for medical injury in the US. Quick compensation outside of the court systems should be the rule, not the exception in the US.

It has been a great pleasure to be able to practice medicine for nearly 25 years. I have been privileged to share the stories of countless people, to share their lives, meet their families, and to interact with physicians and nurses who combine compassion with humor and ungrudging hard work. There is much that is caring and good about the practice of medicine as it is now. The nearly 20% of our gross domestic product that goes into the provision of medical care, even when wasted on tests, procedures, drugs and contraptions that are not helpful, is still contributing to our economy instead of that of China. There is much to be grateful for. However there is also much that can be done to better focus all of this effort and money so that the millions of people who are suffering due to the inadequacies of our system are better served.

Lifeline Screening, prevention and early detection of disease

2011-05-09T23:10:00.000-07:00

Most of what we think of as preventive medicine is actually not that at all. Mammograms, pap smears, colonoscopies, all of these are actually early detection of disease. Abnormal results on any of these tests prompts more testing and sometimes treatment, which may or may not result in better health or a delay in becoming ill or dying. True prevention of disease would include healthy diet, exercise, accident prevention, safe sex and adequate birth control. These are the kinds of things that truly keep people from getting sick, but most of these are not truly in the scope of care provided by physicians.

Today I got a letter in the mail from a company called Life Line Screening, inviting me to "participate in a simple potentially lifesaving screening to assess...risk for stroke, abdominal aortic aneurysms and other vascular diseases." There will be a bunch of ultrasound technicians in a nearby community center who will be eager to check my blood vessels for narrowings, and my abdominal aorta for widening, which might indicate an aneurysm. Any of these tests would cost me $60, but I can get all of them, 5 tests for $159. The tests will be run by technicians and read by qualified physicians and I will get my results in a few weeks. As far as the money costs, this is not at all a bad deal. Any of these tests if done in our hospital would cost much more than the total cost of $159, though I would receive my results more quickly and the level of detail would be considerably higher. The only hitch is that I don't actually need any of these tests, and it is likely that my health related anxiety will be significantly higher than my baseline as I wait for the results.

The US funds a task force to determine which tests contribute to lengthening life and improving its quality, called the United States Preventive Services Task Force (USPSTF.) This group uses the data from many clinical trials to determine who should get which testing and at what frequency in order to maximize health. It turns out that routine screening for breast cancer before the age of 40 (or 50 in the case of low risk women) probably causes more harm than good. Prostate cancer screening for men with no symptoms is also in this category. Screening for prostate cancer in a man who is over the age of 75 is definitely a bad idea, leading to more, not less death and disability than no screening. Vascular procedures such as done by Life Line Screening are mostly not helpful in making us healthier, with a few exceptions and a handful of caveats.

Screening for abdominal aortic aneurysms is definitely a good idea in men over the age of 65 who have ever smoked. This is widely enough accepted that Medicare now pays for it without any co-pay. So if I were the right person to get this test, I would not have to pay anything for it, and my doctor could order it from any hospital that I preferred. Screening for atrial fibrillation and peripheral arterial disease should be a normal part of any physical exam, and ultrasound testing for these things may not add any significant accuracy. Checking the carotid arteries for narrowing is not shown to reduce the incidence of stroke, though it can raise a person's consciousness of the need to reduce vascular risk. The final test offered by Life Line is an ultrasound of the bones of the heel to check for osteoporosis, but that is a really poor test for detecting the strength of important bones, and with expanded insurance coverage for preventive services, most insurances, and definitely Medicare, cover a better test, called the DEXA scan, without any co-pay in appropriate patients.

But all this said, I am not entirely against Life Line screening. I find that the act of scheduling this testing, showing up, and receiving the results in the mail is an important first step for patients that heads them in the direction of taking better care of their health. The community event of having this company come to a church or gymnasium brings people together to talk about health and focus on what might be ways they can postpone or prevent actual disease. For patients who have no regular doctor and receive no medical or prevention advice, either because of lack of money or of motivation, an abnormal result on a screening test such as this may be a very important piece of information.

Another issue that is very interesting here is that pretty sophisticated testing can be provided much less expensively than in hospitals or doctors' offices. How can it be that this company can do an ultrasound of my carotid arteries for less than 1/10th the cost that my local hospital would charge me? The answer gets back to two major factors that increase cost of American health care: liability (the cost of malpractice suits) and third party payment systems (health insurance). Because the company that does this screening does not bill insurance companies and because patients pay up-front for their care, the care is inexpensive. An ultrasound machine and the services of a technician are not very expensive, and the physicians that read the exams can do so very quickly since the scope of the exams is limited. The process does not involve a doctor-patient relationship and refers all patients back to their primary care physician, so they are not liable to the kinds of lawsuits that drive up physicians' fees. The overwhelming popularity of Lifeline Screening and programs like it demonstrate that Americans are very motivated to receive medical care that is slightly substandard if the cost is reasonable. This is not an option being offered to patients by our present health care system. When the American consumer wanted an affordable automobile, the model T was created. In medical care, we seem only to be able to come up with a newer and fancier Mercedes Benz.

Bottom line? If a person has a good doctor, he or she doesn't need a set of 5 Life Line Screening tests. There is no evidence to suggest that getting these done in addition to regular physicians' care will lengthen life or reduce disability. The fact that many of us do not have regular physicians' care due to the cost and difficulty of even having access to a doctor ensures that programs like this will continue to be popular and profitable.

How is concierge care different from capitation?

2011-05-02T22:23:00.000-07:00

Long ago in the late 1900s, that is to say not long after I got out of my residency, wise people had the idea that medical care would be more affordable if patients had a primary doctor who would be paid to take care of that patient and who would act as a gatekeeper to specialty physicians. Because specialty care was so expensive and often use of specialists fragmented medical care, a patient would see his or her primary doctor before being referred to the cardiologist or the surgeon or the dermatologist. Emergencies were exempt from this process. The physician would be paid a flat fee, per year, to take care of each patient. Patients became dissatisfied with this model, feeling that it impinged on their autonomy, and doctors didn't like either the gatekeeper role, or the fact that, in situations where patients were unexpectedly sick, the system of capitation could lead to financial hardship for the physician. Managed care and capitation are not gone, but the words have developed negative connotations and these models are practiced only in a limited manner, often in health care coops such as Group Health or Kaiser.

Now, however, more and more doctors are opting out of fee for service and payment by insurance companies and opening "concierge" services, in which a patient will pay a certain sum of money in return for better than average primary care, including cell phone and e-mail access to the doctor and longer appointments. The doctor is able to offer these services because eliminating the hassles of insurance billing means that the doctor can make just as much money treating significantly fewer patients. Concierge practices run from low cost to high cost, with an average yearly fee of about $1500. Both patient and physician satisfaction is high in these practices.

So what is different about this than a capitated system of payment? Nothing, I think, other than that the contract in concierge medicine is entirely between the doctor and the patient, without a middle man or organization. The patient decides for him or herself whether the price the doctor charges is worth the services offered.

There is some animosity that surrounds doctors with concierge practices, as they are accused of only offering care to patients who can afford to pay their fees out of pocket. I wonder, however, how the out of pocket costs compare between traditionally insured patients and concierge patients. I'm thinking that those costs are probably not that different, and that they might at times favor the concierge patients.

As we shift our ideas of how medical care should be delivered, I think we need to consider the strengths of concierge medicine and combine its characteristics with concepts of capitation and managed care to capture the successes of both. One of the most important issues is to keep patients involved in defining what care they find valuable. No matter how we pay for medical care, it comes down to the fact that the costs are paid from the pockets of the patients, and so they should have direct input on determining what kind of medical care they receive.

Desperately seeking primary care internists

2011-04-30T21:29:00.000-07:00

I practice primary care internal medicine in a group that consists of a few family practitioners, a few nurse practitioners and 7 internists, two of whom are also specialists. (An internist is defined as a physician who specializes in the detection, prevention and treatment of illnesses in adults.) My office is across the state line from our primary office and has consisted of 3 internists and sometimes a nurse practitioner. I see patients in the office 4 days a week and also take care of hospitalized patients. The hospital is a very good but small (25 bed) facility, with cool features like an MRI machine, fully staffed emergency department and rooftop helicopter pad for transferring very sick patients to larger centers, and is a 20 second walk from my office. I think, right now, that mine is about the best job a person could have.

In two weeks, the third internist in my small office will be moving to another state. He has been very productive and has been doing both general internal medicine on some very complex patients as well as practicing gastroenterology. As a gastroenterologist, he does many well reimbursed procedures, and as a general internist he is very efficient, able to see many patients in a relatively short time. He seems to be able to hear the most important issues and deal with them quickly, something I find very difficult, even after over 20 years of practice. When he leaves, many of his patients will want to continue to come to our office, and I and my partner, who is employed by the hospital doing hospital medicine in addition to her outpatient responsibilities, will attempt to absorb these new folks and meet their needs in addition to the needs of our already adequate patient panels while we attempt to find another internist to fill our empty position.

Simple, you might think, to find a person who would want to step into a job with a good salary, a terrific office atmosphere, in a town where mountain hiking is a 10 minute drive away, you can walk to work through a vibrant downtown, and where there are two major universities within only 7 miles. This job is really not a hard sell. This week my partner and I went south to the closest internal medicine residency in the state to personally advertise the availability of this dream job. We attended a job fair at the largest hospital in the capital city, catering to residents at that hospital and some of the other hospitals in the area. It turns out that nearly all of the residents attending the fair were family practitioners who generally have a different spectrum of practice than internists, including children and often providing obstetrical care. There were 4 internal medicine residents who would have been eligible for our job opening in the whole city and none of them showed up. I did really appreciate the chance to talk to representatives of hospitals and clinics all over the state, and to get a feel for the family practice residents. The food was also excellent.

This was only my first personal attempt to find a new partner, so I might still remain optimistic, except that the real numerical data about primary care internal medicine suggests that recruiting a new partner may be way more difficult than I had expected. At this job fair I spoke with an internist who taught at the program and practiced at the hospital. He had it on good authority that this year, 2011, only 175 physicians would enter the work force as general internists after completing residencies. 175 new primary care internal medicine doctors for the whole US. I reviewed what data is available online and found that his numbers could not be far off. There are about 3000 internal medicine residents in each year at the programs around the country and of those, 80% go on to become specialists such as cardiologists or oncologists, and of the remaining 20% more than half go on to practice pure hospital medicine. So at best there might be 300 new primary care internists. When I was a resident, nearly half of the internal medicine residents went into primary care, so attrition undoubtedly significantly outpaces replacement. There is less than 1 new primary care internist for every million people in the US and so a city of a million might expect to get a replacement for a vacated position, but probably not. A town our size, just over 20,000, would have to win the lottery to get a new internist who is capable and amiable and likes what we have to offer. Some older physicians are looking for new jobs, wanting to move to a new place or relocate closer to family. This is another source we can hope to draw from, but these numbers do not hold out much hope for success.

Because it is difficult to hire a physician, some groups use professional recruiters, the same brand of headhunter that many other professions depend upon. Recruiters are a little like the matchmaker from The Fiddler on the Roof, making their money from putting two players together without any real stake in whether the match really works in the long run. Both the job and the physician hiree are often misrepresented. The recruiter is expensive and the process of cleaning up the mess after a mismatch is even more expensive. When a group as small as ours does hire a new partner, that person is guaranteed a salary for the first year, and often it takes longer than that to attract enough patients to be busy. This is not due to any fear of the new doctor, but just a mathematical phenomenon based on the fact that a small office has a correspondingly small flow of patients so accruing new ones is a slow process.

The shortage of primary care physicians is a real phenomenon and will probably be felt by most Americans. With an increased focus on the importance of primary care, there has been a gradual increase in medical students choosing both family practice and internal medicine over the last few years, but not nearly to the extent that is necessary to fill the need. This year there are over 10,000 family practitioners finishing training, which is gradually approaching the maximum number ever (nearly 11,000 in 1996). Medical students entering residency in internal medicine are also increasing, but not to historic levels. Most residents complete their training in big cities, and most want to stay in those same cities when they start practice, so some places are very well endowed with doctors. Boston, for instance, has the highest ratio of primary care MDs to population of any city in the US.

For those of us who live in rural areas or middle America, expectations of medical care will need to change. I have thought that after the age of 65, most people would be best served by having an internal medicine doctor as their primary physician. Since people as they age become more complex, it just seemed sensible that they would want to see a doctor who specialized in the practice of adult medicine. When I first went into practice the family practitioners actively avoided collecting elderly patients and encouraged them to establish with an internist. Unless a person lives in Boston, expecting to have an internist as one ages will be unrealistic. Patients will mainly be seeing family doctors and increasingly midlevel providers such as nurse practitioners or physicians' assistants. There is absolutely nothing wrong with a good midlevel or family practitioner, but a doctor does get better at doing what he or she does, and it is internists who see entirely adult patients, and so we do get quite good at handling very complex problems. Much like the elves in Tolkien's Lord of the Rings it will be sad to see us go.

Why, you may ask, would it be difficult to get people to be primary care internists? It truly is a great job. It is intellectually satisfying, gratifying to be able to share peoples' stories, we are well respected and the pay is not bad. Unfortunately it often does come down to the pay. I have made the same amount of money for nearly 20 years, not corrected for inflation. Most residents enter the job market with nearly a quarter of a million dollars of educational debt, and a job in a specialty offers the chance to pay off this debt more than twice as fast as if one practices primary care. Because of the shortage of primary care internists, many doctors who are employed by large clinics are expected to see 20 or 30 patients in a day which is neither satisfactory for the doctor or the patient. Documenting these encounters often takes many additional hours impinging on family time and quality of life. In my job, since I am self employed, I can sacrifice pay for a pace that makes both me and my patients happy. Specialists are paid more highly for similar hours of work, provide less comprehensive care, and often lead to both more expensive and more fragmented care for patients.

One of the most immediate solutions to the problem of too many specialists and not enough generalists would be to fund the education of doctors who would provide primary care. There are loan forgiveness programs for doctors who serve rural communities, but it is not just rural communities that are underserved, and medical school is still incredibly expensive, outside of loans accrued. In many graduate programs, a student can support him or herself on stipends, but even though medical students provide unpaid care for hospitalized patients, they receive no financial support at all through the four years of medical school. Changing reimbursement to favor primary care, though unpopular with specialists, would certainly provide an incentive to move the best and the brightest into general internal medicine.

Amount of pressure

2011-04-19T08:48:00.000-07:00

Amount of pressure

2011-04-19T08:47:00.000-07:00

Amount of pressure

What is an impaired physician?

2011-04-09T18:44:00.000-07:00

A hot topic in medicine is the "impaired physician". There was a whole series in the throw-away journal Pain Medicine written by a doctor who spectacularly screwed his life up by getting addicted to opiate pain medications, then overprescribing those same drugs to patients and defrauding Medicare and Medicaid by charging for procedures that he didn't do. He proceeded to run off to various foreign countries where he managed to keep himself fed and housed until finally returning to the US to serve his time and probably not practice medicine. The articles he wrote were luridly exciting, definitely not in the category of "there but for the grace of God go I."

Most of us in medicine have had contact with a colleague who has some kind of a substance abuse problem. I personally have had 3 colleagues with whom I worked closely who had trouble with both drugs and alcohol to the extent that their work was affected and they had to take time off, do a treatment program and be supervised after returning to practice. All three were excellent physicians when they were straight, and jeopardized others when they were not. I think the system probably worked for them, preventing irreversible harm and letting them get rid of their demons and return to practice. The stories these physician addicts tell are often pretty similar. They start self prescribing medications for pain, often headaches, find that when medicated they can work through the pain and maybe the work is just a little more fun. Eventually the dose required to treat their condition increases and it becomes harder to maintain normal work habits. The physician starts missing work and is moodier. Finally there is a mistake that leads to disciplinary action or legal action and the jig is up. The physician gets help.

Substance abuse is the impairment we usually talk about, but by far the least common. Training in medicine is painful. The amount of information to be learned is huge, and the competition to even begin the process is fierce. Once the part of training that involves direct care of patients starts, the patient takes precedence and nothing but incapacitating illness is a good enough excuse for not doing the job. Some medical students or residents have been known to do rounds while hooked up to an IV. Because I was out of town, another doctor in my practice worked with the stomach flu, which she had gotten from a patient in the hospital, pregnant, until she went into premature labor and called me to see if I would come back early to cover the patients. I have worked with influenza until the office canceled all of my patients without my permission, then went home and was unable to move from the couch for 12 hours. It was pretty hard to concentrate on that last patient's questions. At least one of the patients at my office caught the flu one incubation period from when they saw me, and got dangerously ill. My fault.

Another physician impairment that affects patient care is fatigue and burnout. Taking call is a fact of life for most physicians, and can involve sleepless nights. Although rules have been enacted to prevent physicians in training from spending too long at work, this is not the case for physicians in practice. A busy night often means a busy day, since sick patients frequently stay sick and require ongoing care. Doctors who work too hard often begin to get a "God complex" believing that they are so important that life cannot go on without them. They agree to work longer and longer hours and become more irritable and unreasonable. They worry about making more money, since only retirement will ease their suffering.

I attended the funeral of the nurse practitioner who shared my office this afternoon. She was a wonderful woman with a big laugh, a delightful smile, a quirky sense of humor, big ideas for changing the world and a huge wealth of expertise and experience formed over 25 years of study and practice. Over the last few months she had been missing more work and had seemed more fatigued. I knew that she had chronic pain related to a motor vehicle accident in the past and a couple of chronic medical conditions, autoimmune, that gave her daily trouble. Her gradual decrease in life force seemed like it might be just a bump in the road, an exacerbation of the conditions that she had learned to deal with over many years. I never questioned her about being sick, since she knew that I was there if she needed me, and I didn't want to intrude on her privacy. She worked until one day she couldn't stand up and so she had her husband bring her to the office. She was profoundly anemic and iron deficient, related to slow intestinal bleeding. She knew it was a problem, but not how bad it had gotten. It is not hard to treat iron deficiency. A blood transfusion provides instant relief, though at the risk of overloading a heart that might have weakened by chronic muscle iron deficiency and overwork. Her color was better after getting blood, but she was still feeling bad. A couple of days after going home from the hospital she became more short of breath and died. An autopsy showed that a large blood clot had migrated from her leg to her lung, a completely unexpected event. She had also had small clots in her lungs over the preceding weeks, which must have been a huge strain on a system already weakened by anemia. I will miss her a great deal.

The solution to the problem of "impaired physicians", myself, my stoic partners and colleagues is not in any way simple. With the looming problem of a primary care physician shortage, there will be even more of a conflict between the need to take care of ourselves and the need to care for our very sick patients. All I can think of to honor my nurse practitioner partner's sacrifice is to consider the many ways in which we can take care of our patients more efficiently, ministering to them in a way that honors what is truly important and backing away from medicine we practice that is defensive or based on reimbursement. Re-working payment strategies and training programs to train adequate numbers of providers is vital. It is also vital to extend the concept of compassion to include the individuals who take care of patients.

Haiti and the conundrum of being merciful without enabling dependency

2011-03-29T19:13:00.001-07:00

I just got back from 2 weeks on the Haitian island of La Gonave. We have a longstanding exchange established between our community in Idaho and several communities there. Last year, a few months after their earthquake, I visited for the first time, carrying medical supplies and planning on delivering care to the injured and ill. In fact there were very few injured and ill, partly due to the fact that La Gonave is very rural and few houses were occupied at the time of the quake. The other important fact was that this part of Haiti, with few if any medical providers, does not support sick or injured people very well and so they either die or recover.

This visit was primarily to study their medical resources, beliefs, health concerns, and to advocate for better sanitation practices and water antisepsis. I was unable to resist bringing medications and supplies, and also stuffed my suitcase with condoms to hand out like candy.

Community organizing around effective ways to use their medical resources went well. They have traditional healers who know herbal medicine which is reasonably effective for common woes which are related to pain of the physical or psychological variety. Health agents have access to some medications and administer vaccines provided by large NGOs such as World Vision. Coverage is far from complete. Physicians, like me, sometimes come and give workshops, and one community said that standard information about maternal and child health really made a difference in infant mortality. All mothers deliver their babies at home and many are without an experienced birth attendant. There are no doctors save the occasional foreign visitor and one or two who provide coverage at the main hospital in the port town of Anse a Galait. Truly dire situations can sometimes be taken care of in that hospital, but transportation from most of the other communities is by the rare truck or by motorcycle, and can take hours over very rough roads. The care is not free, and although a non-paying customer might get emergency care, a debt will be incurred. I pushed community members to pay their providers, even a little bit, send their children to become nurses or doctors, improve sanitation including toilet technology and water treatment. Midwives and traditional healers need to work together and could potentially become more skilled by working with visiting practitioners. These approaches are all possible and community members were receptive.

I enjoyed talking with people about the use of condoms, blowing up condom balloons and demonstrating appropriate techniques on locally available bananas, and I think the people I spoke to really appreciated the talks and the free condoms. Still, many Haitian women believe that a condom, if it breaks, can get lost in the body and kill a person, that many women will be allergic to them and that they are in other hard to define ways more dangerous than unprotected sex. AIDS is quite common in Port Au Prince, a quick ferry ride from the island, and at least one woman with unmistakeable symptoms of HIV stopped me on the road to ask what was wrong with her, having had swollen lymph nodes since the birth of her baby 14 months before. HIV testing is not commonly available and people are so concerned about the stigma that most would not get tested if it were available. Treatment is available through hospitals on the main island, free of charge, but for many people the disruption of their families would make this impractical. Condom use in La Gonave is about as common as it was in the US before the advent of AIDS and a vibrant women's rights community can probably push the acceptance of this technology in the right direction relatively quickly. The international community is eager to provide condoms once there is demand.

Medically speaking, rural Haiti is a bottomless pit of need. Like all bottomless pits, endless resources will not be enough. Despite having the highest (or second highest, depending on what figures you use) ratio of NGOs per capita, most rural areas are not significantly improved in terms of medical care, sanitation or other safety nets. La Gonave is mostly unaffected by NGO presence, other than having a flourishing crop of evangelical churches, which do provide a social structure and usable community meeting spaces. There are nicely constructed "formularies" with medications and examination room spaces, educational posters and almost no staff. These have potential in terms of healthcare delivery but are presently almost useless. Bringing adequate medical staff to La Gonave, supporting them and maintaining a presence would be incredibly expensive, and with the present infrastructure on the island, with almost no resources for most people to make money, transitioning such a program to being self-sustaining would be very difficult. A reasonable alternative to an American style medical system would be to focus on prevention. The most life-shortening diseases in La Gonave are diarrhea for children, injuries for the young men, childbirth for the young women and hypertension and diabetes for older folks, mainly women who become overweight when their children are able to do the heaviest chores. All of these conditions are preventable. Life expectancy in the US increased by 30 years in the last century, of which 25 years can be attributed to public health measures, such as sanitation and injury prevention. The present life expectancy in Botswana of 36 years would be over 70 years without AIDS. These figures suggest that community organization to prevent disease in La Gonave would dwarf the effects of having an adequate supply of capable medical providers.

So why, then, did I bring a bag full of drugs and medical supplies rather than entirely focusing on educational materials? It would have been easier. But the vision of being presented with a very sick person for whom a well chosen antibiotic or other intervention would save a life and being unable to help was unimaginable. I did hand out a few drugs which might have made a difference, but generally the problems I faced were either minor or incurable. Still, I kept flashing back to the story of the little kid throwing stranded starfish into the ocean, arguing "it mattered to that one."

And still I wonder if much of the direct aid being delivered to Haiti, that which is delivered, which is a precious small percentage, is really doing anything positive. Most of the people I spoke to in La Gonave were focused on what I could give them, despite the fact that they have been failed repeatedly by aid organizations, and remain crippled by dependency. Is the provision of free money not simply fostering the economy of desperation that keeps people from being able to shift into self-sufficiency, however slow it may be?

Another metaphor for this is the puppies of La Gonave. The four of us who traveled together (an artist, a teacher, a plant pathologist and me) stayed at houses with families. At each of our houses were dogs with puppies. The dogs were docile, good barkers, gentle with children, chickens and cats and much more bone than flesh. They were fed almost nothing and drank only when they could find wash water that had puddled somewhere. The puppies were also incredibly cute, but slowly dying of starvation. Every one was completely eaten by fleas. They had no names. As a connoisseur of puppies, I was captivated by the idea of shampooing one, feeding it well, eradicating its parasites and taking it home. It was pretty heartbreaking. But puppies in Haiti cannot all survive. There are about the right number of dogs right now, and with no doggie birth control, each female will probably have more than one litter a year, so without adequate control of fertility, incredibly cute puppies must die. The kindest approach, without spaying and neutering technology, would probably be some sort of selective female puppycide, which would be heartbreaking as well. In La Gonave they appear to have chosen starvation as the method of population control. Did I feed the puppies when no one was looking? You bet!

In reviewing this trip, however, I come to the conclusion that mercy is human and irrational and wonderful. Mother Theresa in India not only ministered to the sick and dying but provided an example of kindness in a place where it was often in short supply. (She also neglected to support birth control and condom use, but that is not part of my point.) I am glad that people are kind and give hope to the hopeless. I love puppies. But I think I will focus even more on prevention if I go back to La Gonave next year.

Practicing good medicine by paying attention to the patient

2011-03-02T17:59:00.000-08:00

I just read an article in the New England Journal of Medicine by Sean Palfrey MD, a professor at Boston University School of Medicine in the department of pediatrics. Dr. Palfrey dares to state the obvious, in a world in which the telling it like it is can be the kiss of death. Dr. Palfrey writes:

Every participant in our health care system must focus on ways to optimize health while decreasing cost, at every step of the process. We need to change the financial incentives currently embedded in health care reimbursement systems that reward the use of tests, procedures, consultations, and high-cost therapies. And finally, the legal system needs to be more restrained about pursuing lawsuits when a difficult diagnosis is missed or a treatment fails, to diminish the pressure on health care providers to practice expensive, defensive medicine at every turn.

These are major changes, but today we are far from providing good care for all our citizens and far from achieving health care equal to that in many other countries. We need to incorporate more realistic clinical, scientific, and financial information into practice in order to bring our health care practices, and our health care system, back into balance.

Thank you, Dr. Palfrey. The reason that this opinion is so unpopular among politicians is that it brings up the specter of doctors mistreating or ignoring the suffering of patients in order to save a buck. This is an issue that must be recognized and dealt with in an era when practicing cost effective medicine will be the only practical path. Good medicine and attention to costs can go hand in hand if the physician truly takes the time to listen to the patient and think about the diagnosis. Further, inexperienced doctors need to be able to use the wisdom of experienced colleagues, either by formal or by informal consultation, which requires time and good communication. In many cases, the approach that involves more testing, more complexity and more treatments saves a little bit of time in the short run, wastes a whole lot of money, and leads to more time wasted and poorer patient care in the end.

Fast medicine, slow medicine and the trend towards shared decision making

2011-02-16T23:14:00.000-08:00

It is very common for patients to complain that they don't get to spend enough time with their physician, or that their questions don't get answered. This is more true now than it was 20 years ago, and is a direct result of the fact that physicians are paid, not for taking care of patients, but for seeing patients, not for solving their problems but for spending time, even a very small amount of time, physically in an office with them. Physicians are not paid for talking on the phone with patients, for e-mailing them, for discussing their case with learned colleagues, for evaluating their complex medications with pharmacies or for coordinating care with specialists, caregivers or family members. What we do get paid for, and often well paid for, is office calls.

The other day I read an article published in a trade journal called the American College of Physicians Internist reviewing suggestions made by Dr. Neil Baum, a urologist in New Orleans, in a session of the Medical Group Management Association about cutting office costs. He recommended, among other things, having a scribe take the entire history from the patient, presenting it briefly to the physician who could then pop in for less than five minutes to do a (very) brief exam and tell the patient what he or she should do. Anything educational that would take extra time could be turned into a video that the patient could watch while the doctor was seeing other patients. He stated that using such techniques allowed him to reduce the time he spent with patients from over 20 minutes to less than 5 minutes.

I'm surprised that anyone comes back. Perhaps he really packs some value into that 4.5 minutes, with amazing clinical exam skills and empathy, but it is pretty hard to imagine.

Still, this is not an uncommon trend, this squeezing of more patients into a day of work as a method of making more money.

As I have practiced medicine I have become more and more sure that the key to doing a good job is spending enough time with each patient. This is even more important as we aim increasingly at involving patients in decisions that affect their health. The present buzz word for that is "shared decision-making" and apparently those who write about such things believe it is an important and positive trend. Far from the paternal doctor who hears the problem and delivers the advice and prescription, shared decision making involves understanding a patient's values and preferences, presenting options and coming to a consensus about immediate and contingency plans. Plans that come of such meetings of minds are more likely to be appropriate and to be adhered to by patients, since they not only understand, but have participated in crafting these plans. One such appointment may obviate the need for many more appointments, efficiently using both the provider and the patient's time and energy.

Shared decision making rarely fits into 4.5 minute appointments.

Fast medicine, like fast food, has a place, but lacks substance and quality. Some problems can be treated well, quickly, such as lacerations and warts, but even the common cold needs some explanation and has different implications for each individual. There are situations in which many patients need attention in a small amount of time, and expediting treatment and cutting corners can be necessary. I often see patients who have been unable to get in to see me (possibly because I don't see patients every 4.5 minutes) who have been at urgent care centers. They have all appreciated that such options were available, but often many of their questions were left unanswered, and treatment and evaluation were suboptimal.

I think we need, some way, to figure out how to support slow medicine as generously as we do the fast variety. The fee for service system does not do that at this point, and salaried physicians are often forced to see large numbers of patients by the corporations that pay them, with a similar set of incentives going on.

Health care "rationing" and the case of Pradaxa, the new drug to prevent blood clots

2011-02-12T22:03:00.000-08:00

Very recently a new drug came out which is significantly better than the drug it seeks to replace. Every year many new drugs are marketed, and most of them offer no improvements over what is already in use, but confuse physicians and patients with false choices, and contribute to increased drug costs. Dabigatran, or Pradaxa (its brand name) is a drug which prevents the blood clots that can cause strokes or other serious mischief, and may eventually replace warfarin (Coumadin) which has been in use for decades. It has several very significant benefits, including the fact that frequent blood test monitoring is not necessary and bleeding risk is reduced.

Some background may be useful.

Warfarin (coumadin) was originally introduced as a rat poison because it reduced the little guys' vitamin K levels and thus prevented the production of a few proteins involved in blood clotting. With no available vitamin K rats would bleed to death from minor injuries. Not long after its release as a poison, it became clear that with judicious use, this anti-blood clotting effect could be useful medicinally in preventing dangerous blood clots in humans, and it was approved as a medication in the 1950s. It is used for patients with atrial fibrillation, an arrhythmia of the heart that can lead to strokes, and to treat and prevent blood clots in the legs that can lead to pulmonary emboli, blood clots that land in the lungs. Warfarin has over the years prevented many deaths and disabilities, but because it is poisonous at levels not much higher than the levels at which it is useful, it has also lead to death and disability from bleeding incidents.

There are other chemicals which can prevent clotting, but the ones that are safe and effective are not absorbed in the gut and have to be given as a shot or by vein. Aspirin and a number of drugs like it can reduce clotting by affecting the platelets, but their effectiveness is limited in preventing or treating the clotting issues I mentioned.

Just recently, a chemical that had been used in laboratories because of its effect on various enzymes was modified in such a way that it could be absorbed when taken by mouth and was tested in large studies and found to be at least as effective in preventing and treating blood clots as warfarin. This drug was recently released and is now on the market, called "Pradaxa", by the drug company that developed it, Boeringer-Ingleheim.

Warfarin is not at all an uncommon drug, and is responsible for many visits to my office, as patients come in to have their "protimes" checked, which needs to be done at minimum monthly, and have their doses adjusted. The doses often change due to changes in diet or health status or other medications which change how their bodies respond to this drug. It is also not uncommon to find that a patient has a protime that is too low, thus they are not protected from blood clotting, or too high, such that they are at increased risk of bleeding, or are bleeding. Pradaxa requires no such adjustment and does not have the same drug interactions. A person on Pradaxa is free to go travelling for several months without finding a doctor who will check and monitor their blood tests. A forgetful person on pradaxa is far less likely to significantly mess up their dosage since that dosage is always the same.

So one might think that I will switch all of my warfarin patients to Pradaxa. Perhaps, eventually, but right now this clearly superior drug is financially out of the reach of all but the most financially gifted of my patients. Today the pharmacist I called at my favorite local pharmacy told me that a month's supply of warfarin at a standard dose is about 10 bucks, whereas 30 Pradaxa pills costs about $130. A study recently reported in the Annals of Internal Medicine (http://www.annals.org/content/early/2010/11/01/0003-4819-154-1-201101040-00289.full) calculated that, compared to use of warfarin, use of Pradaxa would save lives, but at a cost of somewhere between $50,000 and $86,000 per year of life saved. That, frankly, is not such a bad deal, when compared to such accepted services as mammograms and pap smears, but is a difficult step to make for insurers such as Medicare at a time when money is tight.

I have put one of my patients, so far, on Pradaxa, but the cost to him is a hardship. He cannot tolerate warfarin and has a real need for an anticoagulant, so he just has to pay the cost. Most of my other patients, when I tell them about the cost, have refused to consider changing. They, mostly, pay their drug costs, and the other costs, including blood test monitoring and hospitalizations for complications of treatment, are paid for by their insurance companies, which are mostly Medicare. Medicare has not limited the use of Pradaxa, but they only pay for part of it, and in the "donut hole" after Medicare drug benefits are used up, the patient will have to pay full cost.

So how does this relate to rationing?

The US government, as far as I can tell as an outsider, is so afraid of being perceived to ration health care that, although they have created a "Patient Centered Outcome Research Institute" to help us define what medical interventions are valuable, they have strictly forbidden this organization to use the common metric of "Cost per Quality Adjusted Life Years" to guide their recommendations . Knowing how much it costs to buy a good year of life is a way that things as diverse as a mammogram and a new drug can be compared to each other. This metric is certainly not the only measurement of importance, but it is tried and true and has been very useful to me.

My patients who refuse to take Pradaxa because it is just too expensive are engaging in a rationing of health care on a personal level. They have decided that they have a limited amount of money and that they don't want to spend a large portion of it on a drug. I respect that. What bothers me is that even though rationing is going on every day in health care, at the level of individuals, corporations, providers and insurers, our government is too squeamish to look at that, and is micromanaging their own Patient Centered Outcome Research Institute and hamstringing its ability to do the job of guiding us in spending our resources wisely.

Because we are unable to make educated decisions about health care spending, we continue to spend too much and our health care budget balloons, having the direct effect that many people have little or no health care while others have gold plated excess.

will there be enough primary care docs to go around?

2011-02-09T19:06:00.000-08:00

no, probably not.

There are a couple of articles in the New England Journal of Medicine about the upcoming shortage of primary care doctors as the newly insured finally are able to pay for medical care. This problem will be most acute in the states with the lowest number of primary care physicians and the highest number of uninsured people. Oklahoma tops the list. My state, Idaho, is right in the middle, and Massachusetts will have plenty of primary care capacity.

The challenge is to get enough graduating doctors to choose to go into primary care. Presently there are not enough graduates choosing specialties such as family practice, internal medicine and pediatrics to replace the docs who are retiring. This leaves foreign medical graduates, midlevel providers such as nurse practitioners and physician assistants and specialists to fill the gap. All of these options have limitations. Midlevels can be excellent providers, but don't have the more extensive training that is provided to an MD and can't always handle the complex problems presented by the old, the very sick and folks with a combination of mental and physical illnesses. We still need primary care MDs, and we need more of them. Because primary care has gotten squeezed, by complex requirements on time, low levels of pay for time spent and excessive demand due to shortages, it just doesn't look like that great a deal to become a primary care physician to medical students in the craziness of training. They can't make enough money to pay their humongous student loans and it looks like a never ending rat race.

When I teach medical students, I present a different picture, because my job is wonderful. Nobody could ask for better. It is interesting and the opportunity to think and meet new people is just what I always would have wanted. My workload is manageable because I live in a town that has enough primary care physicians. But most medical students will be mentored by harried, busy and grouchy primary care doctors who work in large groups where they have little say about their schedules.

Dr. Stephen R. Smith, a Dean at Brown University School of Medicine, has written a genuinely well thought-out and heart warming article about how to produce more primary care doctors. I hope that it will come to something because his ideas are excellent.

http://www.nejm.org/doi/full/10.1056/NEJMp1012495

It is excellent to see physicians solving problems like this rather than expecting the federal government to make laws which really can't do what needs to be done.

repealing health care reform and rescinding payment for end of life counseling

2011-01-23T13:10:00.000-08:00

This last week brought a couple of disappointments.

The House of Representatives passed a bill to repeal the health care reform package: This was expected and "largely symbolic" since the senate will not approve it and the president will not sign it. I think that it is not largely symbolic, but rather largely strategic. It has the psychological effect of making people remain confused about exactly what health benefits they will have, on top of the confusion that already exists due to the complexity of the present bill. Because of confusion and insecurity about the provisions of the health care bill, hospitals and doctors are acting slowly to take advantage of the changes that are scheduled to occur, and so positive changes that would be more likely to make the primarily democrat backed plan look good to American voters will be less evident. As a physician, the stuttering pace of change is frustrating and discombobulating.
Congress decided that they will not pay for counseling about end-of-life choices for patients with Medicare, despite the recommendation that this be done by the Center for Medicare Services. Speculation is that such payments would lead to more "death panel" rhetoric from Republicans. Payments for counseling on obesity and smoking cessation and healthy diet are now paid for as preventive services, but not discussions with patients about whether they would want to be on life support if their hearts or lungs would fail. Responsible physicians do have these conversations with patients, but many are very uncomfortable doing this because they believe that it will be depressing and maybe that it will communicate to the patient the false impression that the doctor is expecting the person to die soon. Conversations about end of life care are difficult and emotionally taxing, much more so than discussions of smoking cessation, and really make a difference in how comfortable a person is in dying. They make the lives of family members better at a time when the pain of grief makes talk of details difficult. I personally will not change my practice with regard to learning about a person's end of life preferences because of the fact that I will not be paid for it. Many doctors, though, are hesitant to have such discussions, and this leads to a crisis mentality during a patient's final illness with associated emotional and monetary costs.

These particular events are not earth shattering, and will eventually come to nothing, as we gradually re-form the health care reform bill to meet our needs, and as physicians gradually come to accept the fact that patients mostly want to be involved in decisions about the medical treatments they receive at the end of their lives. It is hard, though, to watch this wasting of effort and the conflict it produces as we take another step backward in the slow dance toward fixing our health care mess.

Thoughts about civility, love and positive change

2011-01-23T12:34:00.000-08:00

Martin Luther King Junior wrote:

"The ultimate weakness of violence
is that it is a descending spiral,
begetting the very thing it seeks to destroy.
Instead of diminishing evil, it multiplies it.
Through violence you may murder the liar,
but you cannot murder the lie, nor establish the truth.
Through violence you murder the hater,
but you do not murder hate.
In fact, violence merely increases hate....
Returning violence for violence multiples violence,
adding deeper darkness to a night already devoid of stars.
Darkness cannot drive out darkness; only light can do that.
Hate cannot drive out hate; only love can do that."

Congresswoman Gabrielle Giffords is now a rehab facility to learn how to walk and talk again and the families of the folks killed in Arizona are trying to put the shreds of their lives back together and to make sense of what happened on January 8th, 2011. The angry rhetoric and reflex blaming is quieting down among politicians and political commentators. Martin Luther King Day has come and gone and the sermons and speeches that attempt to make sense of his life and death are fading again.

Bloggers have pretty much ceased to argue about whether civility is practical, and about who is the least civil and ought to apologize to whom about what.

Things in the world remain pretty scary, as they mostly are most of the time if one chooses to look at them that way. They are a bit scarier than when the economic indices were looking pretty, because we can all hear the wolf howling at the door of the metaphorical drafty cabins that are our lives. The fear turns to anger, as it often does in the movers and shakers of history, and the anger fuels action, which is more comfortable than inaction when things look grim. The action seems important and the anger seems justified, in such dire times. We talk about civility, but frightened and angry people have trouble with patience and respect and empathy and kindness.

The action that is fueled out of the anger that is fueled from fear can fight a battle or repel an attacker, but it can't build a community or create an idea that unites people to do the hard and complex work of nation building.

Martin Luther King Jr. could get away with talking about love because he was a preacher. The rest of us, writers, politicians and such, can barely squeak out the word "civility" without embarrassment. But it is love, not civility, that gets the job done. Anger, hate, blaming and name calling, righteous indignation and insincere apologies are truly and unavoidably human, but they are counterproductive in a situation where creativity and hard work are what is needed.

I'm not entirely sure how we get there from here. On the subject of health care reform, members of congress and the political parties who influence them continue to argue about which side has the best interests of the country in mind, who wants to help the working poor receive medical care, who is spending the money of the American taxpayer and raising debt, who wants to cut services to those who depend on Medicare and Medicaid to fund their medical expenses. But this is not an issue that is well suited to party politics. It is an issue that requires good ideas and an agreement to compromise and try new approaches.

Psychologists have begun to use the concept of deliberately cultivating gratitude as a way of increasing happiness (http://www.faculty.ucr.edu/~sonja/index.html). Organizational change can be more effective when an approach called "Appreciative Inquiry" is used, re-framing a situation in positive terms and moving in the direction of what is good in contrast to moving away from what is bad (http://appreciativeinquiry.case.edu/intro/whatisai.cfm). It is clear to me that, as a country, our focus on what we don't like, don't want and don't feel is acceptable has been partly responsible for the conflict burdened paralysis that we presently see in our government. A paradigm shift in the direction of love and gratitude is what will allow us to move beyond bickering to forging cooperative solutions to problems that we all want to solve.

And on that subject, on this Sunday morning I am exceedingly grateful for the time I have to sit and think and write, for a full stomach and a warm house and for all of the social reformers who have felt strongly enough about what is right to devote their time and words to their respective causes.

Is the individual mandate constitutional and, more interestingly, is it a good idea?

2011-01-19T22:55:00.000-08:00

Today in the New England Journal of Medicine authors ask the rhetorical question "Can Congress make you buy broccoli?"

We would undoubtedly reject a requirement to buy broccoli, but on the same subject, is it reasonable that the Affordable Care Act requires every American (with few exceptions) to buy health insurance? Although Congress has required citizens to do various things, including pay taxes to fund Medicare, it has never before required that we buy a product from a private company.

Why do we need to buy health insurance from private companies? Mainly because providing a federally funded "public option" for health care coverage was so unpopular among conservatives that there is no public option, and so if we must be insured, our options (unless we are old, disabled or very poor) are limited to buying insurance coverage from the existing private insurance companies.

Despite the fact that private insurance lobbies supported the passage of the health care reform bill, they are still showing a remarkable level of dis-ingenuousness as they rapidly increase the costs of private policies while reducing their coverage in order to recoup losses expected when regulations of health insurance go into effect. These companies will do their very best to continue to increase their profits because that is what they do. Private insurance companies are not driven by ethical considerations. Private insurance companies are driven by the desire to gain market share and pay those they employ and shareholders, in the case of for profit companies, as much money as possible. Requiring people to buy insurance from private companies ensures their ongoing success. I am not sure this is a good idea.

Yes, it is true, that allowing people to remain uninsured means that the cost of medical care will be shared only by those who buy into the system. It will make our affordable care act not affordable. But is this an equivalent evil to mandating that we support an insurance industry that has no vested interest in promoting public health?

A link to the article, with relevant supporting information such as legal precedent is:

http://healthpolicyandreform.nejm.org/?p=13457&query=TOC

Seeing the light: let's use Medicare to change the world

2011-01-03T11:57:00.000-08:00

In medicine, third party payers have been partly if not mostly responsible for price inflation and inefficiency. Because an individual does not pay for most of his or her medical care, there is no incentive for that person to insist on fair pricing and excellent service. Because the third party--an insurance company that may be private or government funded--is not actually receiving services, there is no incentive for that payer to insist on quality, and in most cases higher costs can simply be passed on to the insured.

A solution to this problem could be direct payment for services by the patient, but such a transition would be difficult since prices are already so high that services are unaffordable, and we are deeply entrenched in the third party payment system.

So how do we get our third party payers to act as individuals, and insist on good quality and affordable costs? Right now there is a significant pressure on Medicare to reduce its costs, and so Medicare is a very good place to start.

People love their Medicare. They may complain about it, but the vast majority of folks are very happy to have a large portion of their medical costs taken care of and to be able to count on care when they are sick or in pain. Medicare's costs, though, are going up faster than nearly any other area of government spending, and Medicare pays doctors and hospitals less than private insurance companies, making Medicare-insured patients less desirable to providers and limiting their choices of providers. Often physicians will not accept new Medicare patients and these patients can't even find providers in the communities where they live.

Much of the excessive costs associated with medical care are associated with coding and billing and generally partitioning care into billable units so that providers can submit requests for reimbursement to insurance companies. This focuses providers on the units of care rather than on the care of the patient, is time consuming and counter-productive. The most efficient way to pay for medical care is to pay the provider directly for care of a patient, either by the month or by the year, and have that provider be responsible for the care of that person in the area of their expertise. A physician who cares for 1000 patients can make a very adequate living, including covering his or her overhead, for $200 per patient per year. Hospital costs can be high, but most patients rarely or never use a hospital, so their costs are quite affordable, per capita, as well. Pharmacy costs are high, but much of that is due to insurance billing issues and often use of brand name medications where generics would do, and pharmacies could be quite efficient if they were paid to serve a community rather than per prescription.

What if Medicare offered a comprehensive program to pay for primary care, hospital costs, pharmacy costs and specialty costs? A fixed fee could be paid to providers to deliver services including pharmacies and hospitals and even high volume specialists, and in turn the providers would need to give Medicare administrators data about the overall health of the patients they served, but not bills. If this program were to happen nationwide, patients who were out of town on vacation or who moved from community to community could receive care from Medicare providers without difficulty. Such a program could be started relatively small, as a Medicare option. Medicare would need to fund tertiary care and care outside of the funded providers if it were necessary, which would give Medicare incentive to make sure that health care delivery was effective, that their patients stayed healthy. Providers would have an incentive to keep patients healthy as well, since more health care would not mean more money. Patients would be more likely to see their primary care physician and get to know that person better so there would be more personalized care.

I would love to be a Medicare provider in such a system. My record keeping focus would be on the health of my patients, rather than on billing issues. I would be paid to keep these patients healthy, and would get a regular salary. My case load would be lower since I would have to treat fewer patients to receive a salary, and I could be more efficient since I would be spending less time with billing issues. I would spend more time with each patient since I would be providing true comprehensive primary care.

Those who worry about socialized medicine could use traditional third party fee for service plans either through Medicare or privately, though the number of people who prefer this option would likely drop. This system would be an option only. It would start small so bugs could be worked out, and certainly there would be bugs. But after bugs were worked out by Medicare, private insurance would begin to offer such plans. Medicare was an innovator when it first came into existence, providing comprehensive medical coverage to a whole class of people who had been struggling to receive care. It has now become a poorly functioning and ruinously expensive program with a need to make changes.

I think this idea will happen. It will happen under the auspices of the Center for Medicare and Medicaid Innovation, a program developed under the health care reform law to change the way care is delivered and paid for. It will happen because it is really the only way to deliver care that makes sense without entirely scrapping publicly funded health care and the third party payment system. This system will have to learn from the mistakes of previous experiments with capitation and managed care. Lessons could be learned from the successes of health care cooperatives as well. Such things as massage, home visits and health club membership would be included in benefits, since all of these things efficiently contribute to maintaining health. Nevertheless, patients will have to be patient since major change is never easy. If this works it will work because many committed people put their backs into it, and it will happen slowly.

A system like this will be much less costly and will have a significant impact on our economy in both negative and positive ways. The vast number of people involved in the business of billing and paying bills will need different jobs. The number of people employed by the health care sector will eventually shrink. Money spent on health care mostly stays in the US economy, and if health care is less expensive it will be important to capture that income in some other way. Freeing up workers to do truly useful work will be a challenge and an opportunity.

Medicare and the lemming-like desire for more government funded healthcare

2011-01-02T22:21:00.000-08:00

This week in my hometown newspaper two articles from the Associated Press were featured, representing some major issues about Medicare’s ongoing viability. The first article presented numbers about how the average person’s Medicare tax contributions compare to their average Medicare expenditures. The most often quoted figure (this data is rapidly achieving viral status) is that an average couple earning $89K a year will contribute $114K to Medicare over their work life and require $355K in expenditures by the end of their lives through Medicare. The second article looked at a poll conducted in November of 2010 in which 1000 US citizens age 18 and older who were asked various questions about their feelings and preferences with regard to Medicare, given that it appears to be unsustainable without significant changes. The actual data can be accessed at this link: http://hosted2.ap.org/APDEFAULT/gungrey/Article_2010-12-31-Medicare%20Money%27s%20Worth/id-6f008b3f7edf4a89abe1793d3a9e8955.

Data from the AP poll showed that this randomly selected group of people had very different opinions about what to do with the need for change in Medicare. The articles that I can access online report the same things, in fact they mostly use the same words to report the same things, and report that most of those interviewed believe that although they don’t want to increase Medicare taxes or increase the age at which Medicare kicks in, they would prefer that to having a reduction in benefits. As far as I can tell, they were not told what these hypothetically reduced benefits would be, so that pretty much nullifies the value of that question, but so it goes.

The vast majority also said that they would like Medicare to cover hearing, vision and dental services. If they had been asked, I wonder if they would also have liked to have the government buy them a new car and decrease the work week to 3 days.

Perhaps they should have been asked “In the best of all possible worlds, would you like to have everything you want and be happy all the time?”

But I digress.

The real question, the interesting question, is why the couple featured above should require $355,000 in Medicare expenses after the age of 65. What changes could be made that would keep medical costs affordable while preserving or improving health and quality of life?

I am not a fan of making one-size-fits-all guidelines to decrease costs. Medical costs are huge, though. Each item we do or order to be done for a patient carries a very large price tag, and there are huge numbers of patients requiring these costly items which means that intelligent tailoring of doctors’ ordering behaviors can have a huge impact on overall costs.

In order to make choices that fit individual patients’ needs, doctors need to spend more time with each patient and need to get to know the patients and their families and social settings better. This means that in order to save money, we need to spend money, educating more doctors and paying them more for encounters that actually get the job done. A doctor bills heftily for an appointment in which he or she hears about a cough and prescribes (incorrectly) an antibiotic. For an appointment that takes twice or 3 times that long, in which a person is counseled about health, a connection is made that involves learning about that person’s situation and health related questions are asked and answered might be billed at 30% more, and might easily avert long term problems or expensive emergency room visits. In short, we doctors need to do a better job, and we need the system that educates and pays us to support that.

One of the things that is a costly part of Medicare benefits is the use of brand name drugs where generics will do, and using drugs at all when no drugs will do. That said, there are some patients who require the newest and fanciest drug due to intolerance of or ineffectiveness of the older drug, and a physician who spends time will help that person make decisions like this more effectively.

Another wickedly expensive thing that we do when under time pressure is to order imaging procedures where a good exam or the passage of time would do just as well in making a diagnosis. A CT (Cat) scan may be billed at $2500, and is associated with a dose of ionizing radiation equal to 300-500 chest x-rays, with associated significant risk of future cancers. Use of this kind of imaging is increasing rapidly, with major negative effects, both on our health and on our economy. And as for saving the busy doctor time, it does not, since these imaging procedures often show some irrelevant and often incorrect finding that requires counseling, reassurance and often repeated imaging tests. A thoughtful doctor who takes time, though, will order imaging tests for the patients who can benefit from them. Tests such as CT scans have expanded our abilities to detect serious conditions at a stage in which treatment is effective and less harmful, but trends such as ordering an abdominal and pelvic CT scan for every case of appendicitis is clearly out of line.

Blood tests are some of the least expensive items that we order, but we order them in profusion, often with no expectation that they will be helpful. People expect them at every physical exam, and there is no useful standardization to allow us to limit their use. They are usually confusing or inappropriately reassuring and are associated with many many millions of dollars of excess spending.

There are so many other ways in which good medicine is less costly. It frustrates me to see Medicare’s rising costs viewed as an unavoidable result of medical progress. It seems as if whoever wrote the questions for this AP survey is part of the conspiracy of ignorance that equates limiting health care expenditures with “reducing benefits.” It is just not true that more medical procedures and unneeded medical procedures are a benefit.

When do we get our free preventive health care?

2010-12-16T16:35:00.000-08:00

One of the most exasperating things about the Affordable Care Act (otherwise known as health care reform) is the fact that its many provisions don’t just start immediately, but rather are phased in over a really long period and at seemingly random intervals.

As a physician, I often hear my insured patients say things like “I can’t afford a colonoscopy right now” or “how much will a mammogram cost me?” I tell them that with the health care reform legislation they won’t have to pay for either one of these things. Unfortunately, my response has been a misleading oversimplification.

It is true that one of the most welcome parts of the Affordable Care Act is that recommended preventive care services will be paid for in full, without co-pays or cost sharing. But when?

Medicare and Medicaid programs will begin covering preventive care services at 100% on January 1, 2011. The services included are at this link: http://www.healthcare.gov/law/about/provisions/services/lists.html

Private insurance companies have a year from the passage of the law to comply with this provision. So if you are privately insured, you may need to wait for several more months.

But what about the people who are told by their insurance companies, that, no, they don’t have coverage for colonoscopies or pap smears or flu shots or smoking cessation counseling or any of that stuff? Doesn’t the law apply to everybody?

Because the health care reform law had to allow people to keep the insurance coverage they had if they wanted to keep it, certain policies are “grandfathered” so that they remain the same as they were at or prior to March 14, 2010. Any insurance policy that a person maintains continuously, that doesn’t change its provisions in any significant way, can continue to not provide fully covered preventive care services. If the policy changes its coverage limits or the services it covers, that policy is no longer grandfathered and must fully comply with the law.

Most of the other provisions of the health care reform package do apply to these grandfathered policies, except for the fact that an individually insured person who was not covered for a pre-existing condition that was excluded will remain that way, and that there may not be full coverage for visits to pediatricians or gynecologists.

Why would a person want to stay insured under one of these grandfathered policies? Probably because the private health insurance companies are at this point doing their very best to increase the prices on new policies before many of the other provisions of the act go into effect in 2014 and thus the cost of the newly created policies that conform to the new law is pretty steep, in many instances. Private health insurance is presently going from wickedly expensive to unaffordable for many Americans. Keeping one’s old policy, even with nasty rate hikes may be the only option many people see open to them.

Why do health insurance companies not voluntarily cover preventive services? Surely it saves them money to prevent rather than treat disease. Unfortunately that is not always true. If all women received mammogram screening at recommended intervals, the cost per year of life saved would be 40-50,000 dollars. If a person doesn’t receive timely screening, the breast cancer that results might be expensive to treat, but that will be offset by the many women who never had mammograms. In addition, some people who are not screened for disease die quickly and relatively inexpensively. Those who survive will likely be costlier to treat in the future. It is not in the best interest of an insurance company whose motive is profit to aggressively screen for most diseases.

Marijuana, Darvocet, Colchicine and the ineffective politics of medicine

2010-11-29T22:22:00.000-08:00

The Food and Drug Administration (FDA) has made two bold steps in the last month. They have asked the manufacturers of pain medications containing the mild opiate propoxyphene (Darvon) to voluntarily take these products off the market, and they have removed from the market all generic forms of the drug colchicine that is used to treat gout.

Initially, this all seems ridiculous. Both of these drugs are nearly ancient, with a track record of successes, failures and side effects that goes back decades. On further examination, it still seems pretty stupid, though quite a bit more complex.

We'll start with propoxyphene, the pain reliever. Over the years propoxyphene has been used as a milder, less sedating option for pain that was too severe to respond to acetaminophen or anti-inflammatories. Studies showed, however, that its pain relieving effects were actually no better than plain acetaminophen. Unfortunately, patients thought that it helped significantly more than plain acetaminophen and their doctors also thought that it worked pretty well. It was not nearly as addictive as hydrocodone or other opiates and very old people could often take it without becoming too dopey. It also had an unexpected and very useful off label use as a treatment for restless leg syndrome. In overdose, however, it was more likely to be fatal than some other mild opiates and because of its metabolism, more difficult to reverse with the medications we have to reverse opiate overdose. The final nail in its coffin was a finding that it changed the electrical conduction in the heart, even at normal doses, and that can lead to sudden death. There are some people for whom, in my experience, nothing else works, and for these people the loss of the drug will be a major blow.

On to gout. Gout is one of the oldest described diseases, and is characterized by an extremely painful swelling of joints, frequently in the big toe or feet, caused by an excess of uric acid in the blood. The condition can be hereditary and can be worsened by using many common medications. It can respond to many medications that reduce inflammation, but often these medications are too dangerous. Colchicine is an alternative and has been cheap and effective for many decades. About 8.3 million people have gout, and a sizable minority of these patients used colchicine to prevent attacks or treat acute joint pain. Colchicine has been around so long that the FDA never did any studies on it and so little official science has existed regarding its use, other than the huge personal experience of millions of physicians and patients who have used it over the years. The FDA started a program to study old drugs, in 2006, and the company URL Pharma undertook to do the studies to see what effective doses were and what were the potential pitfalls of using it. We had known that high doses of this drug caused diarrhea and could effect the bone marrow in some people, but the new science also informed us of some medications that, when taken in combination with colchicine, could make it more toxic. In return for doing this research, the FDA granted this company exclusive rights to sell the drug for the next 3 years, and as of right now, or pretty soon, the brand name of this drug, "colcrys" will be the only version available, and the cost will go from pennies a pill to over 5 dollars a pill.

If 1 in 10 patients with gout took this drug as a preventive medicine, 1 pills twice daily, the cost to the US to provide this medication rather than the generic would be about 2.3 billion dollars. This brand name drug is no safer, and in fact no different than the generics that have been available.

So what to do? A person can still buy propoxyphene products online or in Canada or Mexico, but a physician who condoned this would be a sitting duck for a suit if the patient overdosed or had a heart arrhythmia. From what I read, the actual risk of heart arrhythmias may be unknown, and clinically there has been no suspicion of this particular danger over the many years it has been used. A person can still buy generic colchicine in this same way, but it looks like the online cost has already risen significantly just since the press releases have come out letting us know of the recent changes.

What could we have done differently to reduce suffering and make good choices in situations like this? Propoxyphene has been on the chopping block for some time, but research funded, not by drug companies, but possibly through non-proprietary organizations might have given us more information on appropriate uses for it and who, in particular, should not take it due to heart risks. Certainly, with regard to colchicine, academic research on the drug could have saved consumers, and the country as a whole, a significant amount of money. Certainly such research would cost much less than the 2.3 billion dollars yearly that represents the difference between brand name and generic colchicine.

And where does marijuana come into this whole story?

Inhaled cannabis has a very long track record of medicinal use, and has been studied extensively. It remains mostly illegal in most states, and in general is an underused resource for conditions such as irritable bowel syndrome, nausea and various forms of chronic pain. Since most research and marketing of medications is done by pharmaceutical companies, and marijuana is so easy to grow as to be generally unprofitable to a pharmaceutical company, this drug remains in a kind of limbo where legitimate use of it is difficult. An oral preparation of this, Marinol, is available by prescription, but is in fixed doses and works more slowly and is less easy to titrate than the simple burned and inhaled leaf. These pills not only don't work as well as inhaled marijuana, but they also cost significantly more, even than the artificially inflated cost of the illegal leaf.

Pharmaceutical companies have, nevertheless, been very effective in bringing novel and innovative medications to general use quickly and efficiently. Research at Universities is very slow compared to the pace at a well funded, for profit company where researchers are professional and the profit motive makes people work hard. The important issue, here, is to maintain academic alternatives that allow research on drugs that will never be money makers.

The sky is falling! Medicare payments to physicians will be cut by 24.9% on December 1, 2010!

2010-11-18T17:52:00.000-08:00

Since Medicare, the single payer health insurance program for citizens age 65 and over, was signed into law in 1965, medical care for seniors has become more universally available and increasingly expensive. Since Medicare insurance looked to doctors and senior citizens like a blank check, services offered to older Americans rapidly expanded as did their unit cost and consumption of those services. The American government has tried various schemes for reining in spending, none of which have been popular or effective. In 1998, we decided to try the "sustainable growth rate" formula to control costs. Under that law, Medicare expenses were allowed to rise a certain amount, that which was considered to be a sustainable amount, based on inflation and other costs, and if those costs rose by more than the target, reimbursement for services under medicare would be reduced for the next year to an extent that the target of reasonable cost increases could be reached.

In 2002, Medicare payments were reduced by 4.8%, meaning that doctors who treated medicare patients, patients who already paid less than most patients insured privately, received a pay cut relative to the previous year. Many doctors decided that they could no longer accept Medicare insurance, and stopped seeing patients whose only insurance was Medicare. This was an ugly scene, with unhappy doctors and unhappy seniors. After that time, each year's Medicare expenses have exceeded targets and congress has stepped in at the last minute and staved off cuts to Medicare reimbursement. Each year that the cuts are delayed, they are added to the next years planned cuts. Now, by the sustainable growth rate formula, doctors' reimbursements for treating Medicare patients are slated to go down 24.9% by December 1st.

Doctors are wringing their hands, sending letters to their patients and predicting terrible outcomes for the care of seniors. They are also expecting, once again, that congress will step in and avert this crisis. And of course we will be saved again from this cut because the cut is now unimaginably huge. Congress has promised a fix to the sustainable growth rate formula, because this last minute reprieve thing has gotten ridiculous and is a colossal waste of time and effort. But the problem is not the SGR, but rather that providers of care for patients with Medicare do nothing substantial, year after year, to control costs.

Oooh. Saying that could really get me in trouble with my doctor friends.Why, they might ask, is it up to us, who work so hard for such small reimbursement, to reduce Medicare costs? The answer is that nobody else appears to know how to do it, that we have a major stake in making sure that this system works, and that we have large organizations such as the AMA which have the manpower, political clout and most importantly knowledge of the situation to do the job. Congress doesn't know how to do it. They aren't medical. Patients can't do it. It's really up to us.

Where, then, is the waste? Won't we have to deny care to people who need and deserve it in order to cut Medicare costs? Absolutely not. We do so much in medicine that is unnecessary, from CAT scans that are not indicated, to surgeries that don't help, to high tech care at the end of life that was never what the patient wanted, that cutting even a fraction of it would be adequate to balance the budget. Many of the small projects funded by the health care reform bill will help, but the process is by no means on autopilot.

Yesterday I received in the mail the summary of Medicare benefits for my father in law who died in a local nursing home of pneumonia this summer at the age of 90. Both he and my mother in law had become demented, him from multiple strokes and her from Alzheimer's disease. They were at a nursing home where the care is excellent and where they know both me and my husband well. So when I saw that he had been charged over 200 dollars a day for "oral function therapy" which I have determined consisted of having a therapist coach him on eating, I was surprised and disappointed. In the bill I saw, he had charges for this and for speech and hearing therapy which over the course of 2 weeks during which he was mainly doing the work of dying, added up to over $2600. It is, of course, hard to interpret these bills, but it looks like Medicare shelled out something over $1000 for these therapies. That's a lot of money. But multiplied by the over 1.4 million people in nursing homes in the US, it starts to be real money, to the tune of $1.4 billion dollars a year. This particular item is only a tiny issue compared to all of the other nursing home related waste, and nursing home related waste is a mere speck on the horizon of total Medicare waste. The total budget for Medicare in 2010 is about 380 billion dollars, and it really looks to me like cutting 25% of this would not be hard, if we paid attention.

The question that is left for me at this point is what to do about this specific bill. I am in the same situation as many people who get billing statements from insurance companies. The amount that the insurance company leaves for the consumer is pretty small, and I'm tempted to just leave the whole thing alone, after notifying everyone at the nursing home and everyone who is a doctor who will listen exactly what these therapies end up costing. If I call a fraud and abuse hotline at Medicare, they might come down hard on a nursing home that I think is excellent, and the real problem, which is that this sort of thing is going on everywhere, will go unaddressed. If it was my nickel, I would never let something like this go. With an insurance company acting as an intermediary, though, the motivation for an individual, who actually knows the value of the service being given, to make the kind of fuss it takes to reduce costs, is limited.

Health Insurance Premiums go up, again

2010-11-01T22:14:00.000-07:00

A year ago I decided to shed my company health plan and buy an individual plan with a high deductible for my family. The cost of my employer plan had reached nearly $900 for my family of 4 who never use health insurance, and the deductible was $1000, which meant that any care we have received in the last 10 years would have been unreimbursed. I found a plan with a deductible of $7000, which I could combine with a Health Savings Account for $481 a month. How clever, I thought. I have really bucked this system!

I just got my bill for the health insurance plan that Premera Blue Cross decided to provide for me in place of the plan that I signed up for a year ago. A few weeks ago I had received a glossy color sheet describing how my plan was changing, due to health care reform. My new plan would cover all health maintenance with no charge to me out of pocket, but would no longer have any coverage for various alternative medical services or eye care services. The overall deductible would be the same.

How much, you may ask, is this new plan that sucks marginally more than my previous plan? It is now about $630 bucks a month, a 30% increase over last year (with no dental coverage). As far as I could tell, there is no cheaper, crappier plan available to me. I will just have to suck it up and pay the extra nearly $2000 a year for my really truly catastrophic coverage. This will, of course, cover my deductibles on preventive services, which might have added up to as much as $200 a year with the previous plan. These figures are lower than many Americans’ since our family has no medical problems and our state has some of the cheapest medical costs in the country.

The Seattle Post Intelligencer reports that Regence has raised rates in the double digits for 4 years in a row, on average 91% since 2007. They have a nearly 1 billion dollar surplus, which increased 12% in the last year. Provisions of the health care reform bill will make health insurance more competitive, but not until 2014. That is plenty of time for insurance rates to double and then some.

Most people are in exactly the same situation that I am in, or worse, no matter whether they are insured by their employer, by the military or by the government through medicare or medicaid. To some extent, everyone has a bite taken out of their overall income due to the cost of insuring for health care. The cost of health care itself continues to rise, but much more steeply because health insurance companies continue to pay for these expenses, make the billing for them more difficult and therefore more costly, and hand all of those costs over to the consumers of health insurance with a hefty and increasing markup.

What shall we do, then? I do hope we all become uncomfortable enough with the status quo that we begin to calculate the true cost of a good health care system and re-evaluate what place our present third party payment system should have in it. Negotiating payment for the services that we as individuals or communities need and buying those services would take a great deal of cooperation between providers and consumers, but could radically reduce our dependence on health insurance companies.

An example of paying for expensive services in a proactive way is our local air ambulance service. We are a rural area and many serious injuries or cardiac emergencies are treated in our nearest big city which is 90 miles away. Sick patients are transported by Northwest Medstar to Spokane by helicopter or fixed wing plane, at a cost of over $20,000 per ride. Blue Cross will pay 30% of this if they even agree that the transport was necessary. For $59 a year, a person can buy a “membership” to Medstar which covers any air transportation needs. This is not charity, but simply a calculation by medstar of what it costs to support their services.

There are no other alternatives to our present insurance coverage that are available to me and my family at this point that are not either irresponsible or more expensive. I will continue to push for a community sponsored alternative to health insurance. Our hospital could make this happen if there was adequate cooperation from the doctor groups in town. Even without that, we could do a smaller pilot project to provide primary care, lab, hospital and imaging services. The incentive to do something like this will continue to increase as premiums rise. Interest in this has been high with our hospital’s administration and regardless of tomorrow’s election outcomes, I expect to see creative grass roots alternatives to our present third party payment system.

The Physical Exam

2010-10-17T20:41:00.000-07:00

The New York Times has taken note of Abraham Verghese's efforts at Stanford University School of Medicine to revive the art of examining patients. One gets the idea in this article that most medical schools have let the entire subject slide, which is not true. Nevertheless, enthusiasm for the hands on aspect of data gathering has declined somewhat. When I was in training about 25 years ago, my clinical teachers took the subject of teaching us how to identify pathology in a patient seriously. Johns Hopkins medical school was at that time held up as a model of a clinical teaching institution, so training medical students and residents in the arts of examining hearts, blood vessels, livers, spleens, bones and joints was clearly going to be part of the curriculum. Many patients who moved through the clinics and hospitals associated with Johns Hopkins donated important pieces of their time and dignity in the service of teaching what would be generations of physicians how best to do this. When I finished my training, I felt confident enough to continue to teach myself these skills as I treated and examined 10s of thousands more patients.

The perceived value of the physical exam, however, has taken many hits in the years since I graduated. Well known and oft quoted studies showed that even specialists in liver disease could not tell the difference between belly fat and fluid in the abdomen, that cardiologists couldn't agree on the identity of the many heart sounds associated with failing hearts and valves, and gynecologists were unable to identify ovarian cancers by physical exam at a stage when it had an impact on survival. Many doctors began to back off on the level of intensity of their examinations, partly because they were not entirely sure whether they believed what they saw, felt or heard in a patient's body. Technology such as CT scans, MRI scans, x-rays, ultrasounds and mammograms became much more universally available, and we began to rely on them more. Very little was said about the fact that these, too, are inaccurate in many cases, and only now are we beginning to recognize the fact that both the radiation and the costs associated with these tests carry a significant toxicity.

A good examination takes some time. It doesn't necessarily take much time, but in the hands of a doctor who is not comfortable performing it, the choreography is tricky. In large practices where doctors are expected to see patients at 10 or 15 minute intervals, there is not enough time to have a patient undress and be examine, document the findings, order the appropriate tests and prescribe the appropriate medications, especially if the physician is expected to actually speak to the patient about what is going on.

Teaching the physical exam is part of the art of medicine. Over the years that a doctor practices, he or she will see many presentations of many diseases and develop theories about what findings are indicative of things such as prognosis, response to treatment and subtleties of diagnosis that were never a part of their training. If that physician has an opportunity to teach, these pieces of knowledge will be passed on to students who will further cultivate it based on their experiences. Many of the "clinical pearls" that are developed in this way can never be scientifically tested, but will have immeasurable value.

Much of the information I get from examining a patient, looking in mouths, listening to hearts and lungs, feeling thyroids and lymph nodes, doesn't influence my diagnosis or treatment of a patient, except due to lack of unexpected findings. As a betting person, since the majority of physical exams are normal, I might choose to simply not do them, and assume that they are normal. It would save a lot of time. But without a physical exam, the two of us, me and the patient in the room, are just talking heads, telling interesting stories. Humans are made multisensory creatures, and our communications are best when they include all of our senses. Even the crudest of my senses, my nose, tells me information that is valuable. The touch of hands to skin is a communication that involves two, and the information flows both ways. A patient can sense my confidence, empathy, skill or lack of it. Facial or body movement in response to my hands tell me what kind of problem, how serious and how the person being examined handles illness.

I appreciate the fact that Dr. Verghese is tackling our lack of enthusiasm for the physical exam, bringing his obvious joy in the subject together with his charismatic teaching style to get a new generation of doctors excited about what they can do with their own hands, ears, eyes and noses. Those of them that teach will undoubtedly allow his gift to keep on giving.

This is a link to the article on Dr. Verghese in the New York Times:

http://www.nytimes.com/2010/10/12/health/12profile.html?_r=1

What now? What must we Champions of Medicine do, other than not spend $5000 to attend Newt Gingrich's party?

2010-10-12T22:54:00.000-07:00

Quite a number of perfectly adequate and hard working doctors have been invited to go to Washington to dine with Newt Gingrich. Most of us have decided not to go, though the tenderloin did sound tempting. But now that we aren't going, and health care reform is most likely a done deal, what is left for us to do? We are the Champions of Medicine, so are we just supposed to throw our capes over our shoulders and ride off on our white horses? "My job here is done..." I will say, as the music starts and the credits begin to roll.

Despite our hard work over the last harrowing year, there are still some problems with the American Health Care System, as it is sometimes called. It is too expensive, costs are rising and people are suffering because they can't get the care they need.

What have we gotten with the Affordable Care Act? We have funding for various projects aimed at making medicine more cost efficient and we have payment methods, public and private, that will make it possible for more people to get medical care at a cost they can afford to pay.

This is a major step in the right direction, but there are some major missing pieces. Mr. Gingrich would like to scrap it and start over, but then he clearly hasn't read it since he thinks we now have socialized medicine. Much of what wants to be improved in medicine can't be legislated, so I would like to keep what we now have and see what else needs to be done.

Costs are still rising and this is, at least at this point, threatening to stifle economic growth at a time when our country is struggling to be competitive in a world market where medical care is not a major part of the cost of doing business. This needs to be turned around quickly.

Despite new regulations requiring insurance companies to make policies cover basic medical needs at a cost that people can tolerate, insurance products are even now getting more expensive and less generous. Our continued reliance on insurance to pay the bills not only limits any incentives for costs of medical care to go down, but makes the insurance companies powerful enough that they will certainly have a significant influence on policy which will lessen the effectiveness of the regulations.

Doctors don't understand the new laws and are fearful and suspicious. This is causing doctors who have been in practice to consider narrowing the scope of their practices so they are less vulnerable to public insurance changes, and in many cases to consider retiring. The widespread experience of being sued for malpractice already shortens the careers of many physicians, and the lack of any serious attempt of the recent bill to solve this problem has disillusioned many of us.

So what must we do?

First costs need to go down. In looking at everyday medical practice as it goes on in my community it is clear that much of the excess money spent in medical care is due to the whims of care providers, inadequately informed by science and without knowledge of the costs involved. Almost nobody knows what most of the tests or medications we prescribe cost. Merely being made aware of costs, coupled with more widespread education on appropriate use of medications and testing would make a huge and nearly instant impact on medical costs. This can happen, but could be facilitated by our national organizations. If they are unable or unwilling to mandate transparency of costs and provide leadership on appropriate care, we can do this at a local level through working with our hospitals, clinics and pharmacies to share information.

Costs could also be impacted by changing the way physicians are paid. If we were not only aware of costs but were paid to care for a group of patients rather than by the individual encounter, there would be strong incentives to keep patients as healthy as possible so that they didn't require doctor visits or hospital care. This would line our incentives up with what patients really want: for us to keep them healthy and care for them effectively when they are sick.

One way of providing health care of this type would be through community health care systems on a cooperative model. Communities of people already spend huge amounts of money on health care, and if they pooled those resources and that money did not need to move through an insurance company in order to pay for necessary care, it would buy a great deal more health care. The health care bill supports creation of structures like this, but does not in itself make them happen. That is up to us, in our communities.

I'm not sure it is possible to reassure doctors that all will be well as health care reform goes into action, but if our own national organizations, such as the American College of Physicians and the AMA, show leadership in making our own positive changes we will all feel more in control of the process.

Suing for malpractice continues to be the dysfunctional approach often taken when a patient has a bad medical outcome or a mistake is made, especially if care was very expensive. We can, even now, tackle this in our communities by making ourselves aware of bad outcomes and medical mistakes and offering compensation as well as honestly evaluating what went wrong. This process can be done by hospitals and clinics, and has been shown to reduce costs overall. Suing for malpractice destroys lives of both injured patients and physicians, as they spend years in rancorous argument, and the medical community then loses the opportunity to learn from mistakes. Any federal law reforming medical malpractice is certainly years away, since the tort system has traditionally been a way to protect those who are vulnerable, and it is hard to make the case that medical injury should be handled differently from other sorts of injury.

I'm thinking that perhaps there is still quite a bit of work for all of us Champions of Medicine to do. I think I'll save my 5 grand and travel expenses and hotel fees and just hang out here at home and work on this stuff.

Newt Gingrich invited me to a party!

2010-10-04T22:41:00.000-07:00

Today I received an invitation to an election day party from Newt Gingrich himself! Apparently I have “made the cut” as one of the 2010 Champions of Medicine and will receive a handsome certificate at an election day party at the historic Ronald Reagan Building in Washington D.C. Newt has confided to me that he has worked tirelessly of the course of his career for health care reform. He understands that I have faced challenges during the Obama administration's first two years and that this year has been especially difficult for me with the “Democrat held Congress essentially dismantling the world’s greatest healthcare system and replacing it with the failed model of socialized medicine.”

Newt wants me at the party mainly because he wants to be surrounded by the best and brightest this country has to offer on the “night we set the wheels in motion to repeal Obamacare and replace it with real, meaningful reform.”

Wow.

I would love to go! I would have absolutely no hesitation in asking uncomfortable questions and spreading sedition among the gathered faithful. For all the good that would do. But life is so full of really great things to do that don’t involve being in Washington DC on election day. There are long walks to be taken in the woods. There are songs to be sung with friends. There is a conference to be organized about appropriate use of technology at our hospital. There is real information about what is going on in my field to be read and digested and maybe turned into essays on why the finest healthcare system in the world fails to take care of its own at an affordable price, and how it can be tweaked to face its challenges. There are stories that need to be heard, poems that need writing, children to be raised, jokes to be laughed at.

I’m still filled with questions about this invitation, though. How stupid does he think doctors are? Are we really stupid enough to think that the reform package dismantled the finest healthcare system in the world and replaced it with socialized medicine? Why invite me? I’m not even Republican. Could he have invited many thousands of doctors, and if so mustn’t he believe that his message would sway very few of them, since he can’t feed thousands of doctors dinner at the Ronald Reagan building? And if I did go, what are the choices of entree?

what do I mean by cost effective medicine?

2010-09-20T15:39:00.000-07:00

It is not uncommon for comments about cost effective medicine to be met with mistrust by patients. Saving money is fine, but not if it means that when I, personally, as a patient, am in pain or sick, will have to wait for relief, get suboptimal care or be denied a life saving treatment. I, as a doctor, am also a patient, and can fully sympathize with this opinion.

When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions. Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little value in terms of maximizing health or happiness.

1. I go into the emergency room with severe abdominal pain and before anyone asks me questions that might be relevant (have I ever had this before, what did I just eat, have I ever been evaluated for this and how...) an abdominal and pelvic CAT scan are ordered and I receive a radiation dose equivalent to over 300 chest x-rays and a bill for $2500.

2. I reach a ripe old age, am having significant problems with my memory, joints, digestion, plumbing and whatnot, and suddenly my heart stops while I'm sitting at a meal at the nursing home. I am resuscitated, rushed to the hospital where I remain on life support for a couple of weeks with lines and tubes and beeping machines as my family tries to figure out whether I really would have wanted all of this. Costs for this kind of end of life care often run as much as $10,000 a day.

3. I go the the doctor for high blood pressure, and sure enough I do have high blood pressure. He goes into the sample closet, gets me the newest anti hypertensive medication on the shelf, shown by drug company sponsored studies to have minimal side effects, and I take it, then fill the prescription which costs about $300 a month when a generic of proven track record would have worked just fine and cost $4.

4. I have chest pain and tell my doctor. She wants to make sure she isn't sued if I have a heart attack, even though my chest pain is only with taking a deep breath and is never associated with exercise, so she orders a nuclear imaging stress test. The radiation dose is huge and the bill is $6000. Later I get lung cancer, and cannot be at all sure that it wasn't caused by radiation.

5. I have knee pain and am overweight. I can't get dietary counseling because my insurance doesn't cover it, but I can get an x-ray, then some arthroscopic surgery which doesn't help but costs about $30,000. I now am overweight, have knee pain and a nifty scar on my knee.

6. I am uninsured or underinsured so can't really afford to go to a primary care doctor for my cough. It gets worse, so I go to an emergency room. The evaluation includes a chest x-ray, breathing treatments and an expensive antibiotic and no followup or smoking cessation advice. I didn't need the antibiotic and get antibiotic associated diarrhea and eventually require hospitalization. Total cost of this perfect storm is in the 10s of thousands of dollars.

7. I am an 80 years old man and go to my doctor for a physical exam. He says that I need a prostate exam and PSA testing for prostate cancer. He finds prostate cancer, I get evaluation then radiation therapy, causing me to decline to the point that I now need to be in a nursing home because of urinary and fecal incontinence. I would not have died of the prostate cancer had it gone undiagnosed.

8. I am a 40 year old woman, go in for a physical and am told to get a mammogram. The mammogram is abnormal so I get another 6 months later. It is still abnormal so I get a biopsy. The biopsy is normal. When I get my next mammogram it is abnormal too because I have a scar. I get an MRI of my breasts and that is equivocal. I get another biopsy which is normal. This process is repeated yearly until what is left of my breasts resembles the surface of the moon.

There are cost effective solutions to all of these problems which rely on adequate access to primary care physicians and good choices about when to use technology. Making medicine cost effective is about making it better. Dollars spent on health care should be in the service of health and happiness and nothing else.

JAMA commentary article suggests teaching medical students to be cost conscious

2010-09-18T20:07:00.000-07:00

This week's JAMA presents an article by Samuel Sessions MD of Harbor UCLA Medical Center and Allan Detsky of Mount Sinai Hospital in Toronto suggesting that teaching medical students to be aware of cost when learning to treat patients. They recognize that physicians have an ethical responsibility to pay attention to the fact that medical expenditures are increasingly threatening America's economic viability and point out that training in cost-effectiveness needs to start in medical school.

A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtful and visionary authors which have informed readers. The JAMA is a free publication, at least the print edition, to physicians, and is at least partly subsidized by advertising, as are many medical publications, and its circulation is huge. I have continued to receive it since my membership has lapsed and I am grateful for that.

Today when I decided to share this article in my blog, I attempted to access it online and found that I will have to subscribe to the online version if I want to copy and paste its text into this commentary. I'm not ridiculously cheap, but I haven't yet decided that I want to give money to the AMA. Luckily, this article has made quite an impression in various online sources, so I will quote ScienceDaily:

"The commentary is written by Samuel Y. Sessions, MD, JD, a Los Angeles Biomedical Research Institute (LA BioMed) investigator, and Allan S. Detsky, MD, PhD, Departments of Health Policy Management and Evaluation and Medicine, University of Toronto.
"New physicians will be at the hub of the health care system throughout their careers as both patient advocates and allocators of resources," the authors write in the JAMA commentary. "Instead of considering economic forces to be extraneous, medical education should develop approaches to better equip physicians for this dual role through improved teaching of evidence-based medicine that reflects both economic and statistical realities. Good patient care and good public policy demand no less."
The commentary notes that health care spending continues to grow, reaching 17.3% of gross domestic product in 2009. It points out that physicians "play a critical role not only in the well-being of their patients but also in the nation's economic welfare" as they make choices about how to care for their patients. As a result, the commentary calls for "incorporating information about economic realities into medical education to enable physicians to make better-informed decisions for patients and for the United States."
The authors point out that physicians' diagnosis, choice of medication and course of treatment can affect spending and patient well-being for years to come. To ensure economic realities are part of the physicians' decision, the authors call for a "core, required medical school course that would consolidate and integrate elements of existing health policy, ethics, and evidence-based medicine courses and modify them to better reflect overt and covert economic influences on clinical decisions."
The authors also call for revising "the remainder of medical school and residency curricula" to incorporate economic realities so that the medical students and residents would take these into consideration in their medical decision-making.
"The primary goal of incorporating economics more directly into medical education would be to improve physicians' critical capacity to assess all factors affecting their decisions, as well as their social and ethical implications," the authors write.

This is all extremely heartening. I was especially pleased to find the article quoted so many places, because it is all well and good to have a great idea, it is something quite different to do something about it. When many people are excited, as they seem to be, momentum may build in the direction of change. The next step in such a thing would be to have the idea attach itself to some money--perhaps a grant to medical schools that try it. Medicare already funds a great deal of medical education and perhaps the proper direction for this to take would be for folks in the new center for Medicare innovation (part of the health care reform bill) to notice that it is a terrific idea and stipulate that medical schools receiving funding from Medicare begin to teach a comprehensive curriculum based on cost effective care.

Treatment of Sleep Apnea--the cost of a good night sleep

2010-09-15T21:56:00.000-07:00

Obstructive sleep apnea (OSA), that is snoring with episodes of not breathing, probably affects more than 1 in 20 people. It is most common in older men, though certainly not limited to this group. Risk factors include obesity, large neck size and limited room for air passage in the back of the throat. When a person has OSA he or she may wake up hundreds of times a night as breathing is stopped by floppy tissue in the airway and the drive to breathe arouses them enough to take an effective breath. This loud irregular snoring and snorting also interrupts the sleep of a partner in the same bed. People with sleep apnea have a lousy quality of sleep, rarely reaching the lower sleep levels and are less productive during the day than healthy sleepers and often fall asleep in meetings, movies and while driving. Years ago we discovered that application of a mask to the nose which applies a constant air pressure to the breathing passages can improve nighttime breathing and nighttime sleep. These are called CPAP (constant positive airway pressure) devices and are now commonly used in the treatment of OSA. People who use these devices have better oxygen levels during sleep, which benefits their hearts and brains, and usually feel more rested during the day.

This sounds really good so far. Treatment of sleep apnea is a success of modern medicine. Using CPAP is pretty easy, causes no major side effects and relieves suffering. A slam dunk. Unfortunately the process of getting tested for sleep apnea plus the CPAP machine and supplies is tremendously expensive. In order for an insurance company to cover their bit of the CPAP equipment, a sleep study must be completed and if OSA is diagnosed, another sleep study must be done to see what settings to use for optimal treatment. This involves the patient spending the night in the hospital while hooked up to a machine that measures brain waves, limb movements and oxygen levels. At our hospital a sleep study costs over $2500, the physicians reading of the data costs nearly $600 and those costs are usually multiplied by 2. The evaluation can be done with one night and that is a bit cheaper but still no great deal. At our local durable medical supplier the CPAP machine and supplies cost close to $2000 and some of those supplies need to be replaced several times a year. With good evaluation and a good medical equipment supplier who follows up regularly, about half of the people who are diagnosed with sleep apnea can tolerate CPAP.

There is another option, though, that appears to work for some people. A device that is quite a bit like a boxer's mouth guard can be made which places the lower jaw in a jutted position and improves breathing without the mask and tubes and such. These oral appliances are carefully fitted and are amazingly expensive. One of these things costs around $1200-$5000. Why? All I can figure out is that the cost is competitive with CPAP and is the only viable option for people who can't stand a tight mask on their faces. Why doesn't someone make one that seriously undercuts the rest? I'm not sure. Perhaps because the market is small. It sure seems like an insurer or an uninsured consumer could take a look at this not very complex piece of rubber and refuse to pay more than it is actually worth. Apparently that is not how things work.

It is definitely true that people feel better with better sleep. It is wonderful that the treatment of sleep apnea is such an active field, but none of this stuff needs to be this expensive. This is yet another case of the free market system not acting to lower costs because the actual consumer rarely pays for the product. Insurers pay for most of these costs, and why they agree to do so is beyond me. A sleep study should not cost $3000. In fact, most people who have sleep apnea have really pretty classic symptoms and could get by with a test called an autotitration, in which the CPAP device is set up to adjust itself and a less expensive data set is gathered by a simple device that measures oxygen levels. I asked the durable medical supplier how much they charge for an autotitration and they said that there is no charge.

What about the machines themselves? Many people with sleep apnea eventually quit using their CPAP machines because they are too uncomfortable or too inconvenient, or because they lose weight or die. What happens to these expensive machines? Usually they go to a garage or basement somewhere and become a home for spiders. Because they are regulated as a medication would be, they cannot be sold without a doctor's prescription and durable medical suppliers do not refurbish them. E-bay doesn't sell them, but there are companies that refurbish old ones and sell them online. These machines can cost as little as $100-$200. I'm not sure how these companies get around these regulations. Occasionally a person can pick up one of these things at a garage sale or Goodwill, but this is illegal and it is not straightforward to adjust them. Certainly a motivated medical profession could manage to make use of all of these wasted machines.

A reasonable conservative estimate of the number of treated patients with sleep apnea in the US would be about half a million, and the cost to treat per person at the very least $6000 each. If the cost of evaluation were reduced to the cost of a heavily discounted CPAP machine which could do an autotitration for diagnosis (we will call this cost $1000 for simplicity sake) the cost savings without sacrificing quality would be over $2 billion.

Electronic medical records, revisited

2010-08-24T22:12:00.000-07:00

Last night I realized that I actually do like having a computerized medical record system.

I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007. We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric's Centricity product. It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system "went live" we all slowed our history taking and record keeping to a snail's pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn't deal with it and had trouble retaining a couple of newly hired physician because it was difficult to use. We kept better records, eventually. Some of the nurses and other office staff couldn't adjust and left.

Sounds bad, I guess.

But there's more. It would freeze up when we did certain things that were supposed to work, like faxing a prescription, and stay frozen for 5 minutes before resetting itself. There would be system updates which caused new bugs to appear. If one person was using a document, another person would not be able to use the document until various closing rituals were performed, and if they were performed wrong, a chart could be in a state of limbo that only the IT guy could fix.

Now these problems are only a bad dream. There were other ones too which I thankfully can no longer remember. We are left with only the bugs that seem to be completely resistant to all attempts to treat them, and bugs that are intrinsic to the system.

There is no back button. There is no automatic spell check (though you can spell check manually). Once a document is electronically signed, it can't be changed, and it is easy to accidentally sign a document. There are no autocomplete functions. My cursor jumps, and so when I am typing, all of a sudden I am no longer creating text and I have to manually put the cursor back where it is supposed to be. Sometimes the jumping cursor will randomly highlight text and then when I start typing again it deletes the highlighted text. Occasionally vital signs are entered and just don't appear on the final document, but you can make them appear by re-entering any value into the form. Documents are much longer than they need to be and look awkward. I can't look at a patient's medical record in the same window that I am using to take their history.

When I tell people this, they say, "oh, you just have a bad system." Well, yes, obviously that is true. Nevertheless, this General Electric product is one of the most widely used medical record keeping systems, and being able to communicate with other medical offices and hospitals by way of shared software is one of the major reasons to computerize records. The obvious solution to bad electronic medical records system is to create a great electronic medical record system and make it inexpensive or free, perhaps supported by a government grant, so it out-competes all of these other really-not-very-good systems that we have adopted for lack of a better options.

But that was not the story that I wanted to tell.

I actually wanted to say that providing medicine the way I think it should be done, at a time that is appropriate and in a place that is expedient, has been made much easier by the fact that I can access a patient's medical record from my laptop, anywhere I have internet access, and can send prescriptions and keep records in a way that lets me review what has happened, and later to remember what I have done.

Yesterday when I got back from backpacking, where there was no cell phone service and even google earth couldn't find me, I found a message on my answering machine from a patient who needed help. I was able to sit down at my laptop, see what medications she was taking, see what, if anything, other doctors in my practice had done for her, and discuss medications, side effects and interactions with her. I was then able to order the appropriate change in medication and relay it to her pharmacy, which would get the information the following morning since it was 9:30 at night. It was good medicine, practiced at the most appropriate time for me and the patient, and there were minimal associated costs.

Electronic communications have expanded the way that medicine can be practiced, including the possibility of web based communications to patients with shared problems, e-mail communication, video chatting and efficient communication between doctors of different specialties. I don't use even a fraction of what is available, but I can certainly see what powerful tools exist.

Many things get in the way of making these electronic tools acceptable in our practices. The difficulties in buying functional software like I described in the first several paragraphs is one barrier. Issues of protection of privacy are another. Not least, however, is the fact that the majority of physicians are still paid only for face to face contact with patients, and there is no easy way to change that without fundamentally changing the business of medicine.

We could, of course, simply start charging for all forms of communication, and remain in the "fee for service" model. This would involve more complex billing plus long and incredibly irritating negotiations with public and private insurance companies. We could also fundamentally change the way health care providers are paid, and pay people like me salaries to do the jobs we now do without the complexities of scoring each problem solved, procedure performed or patient seen.

I think that electronic communication and record keeping can, at best, provide an excellent backdrop for community funded health care. Most physicians loathe the complexities of billing for the minutiae of our work, and we would love to be able to put all of our hearts and energies into the actual care of patients. If communities were able to hire the services of hospitals, doctors, nurses and other staff, we would be able to care for people using all of the appropriate and available technology. Our present system of billing keeps most of us firmly entrenched in communication technology that is many decades old.

Estrogen: the pendulum swings again

2010-08-12T22:03:00.000-07:00

The following essay addresses the present tendency of scientific medicine to rely heavily on studies which address the effects of treatments on populations rather than individuals. It has been clear, always, before and after various large scale studies of the effectiveness of estrogen, that hormone therapy is good for some people and not good for others. Nevertheless, at great cost to patients in money and time and quality of life, we have at various times pronounced estrogen to be good either for everyone or for no one.

When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil. It was a bad year for estrogen.

In the 8 years since then doctors, researchers and menopausal women have gradually processed much of the information that came from that large, double blind multi-center trial, and recommendations have matured. It is clear that conjugated estrogen plus medroxyprogesterone is not good for preventing dementia and leads to an increased incidence of breast cancer, heart attacks and strokes. Statistically the combination of hormones does not lengthen a woman's life, but then it doesn't shorten it either. It does reduce hip fractures, colon cancer and diabetes. Some women feel better on hormones and some feel worse, but statistically quality of life is a wash.

But WHI was a huge study, involving over 160,000 women over more than 12 years. The amount of data from this group of women is tremendous and it is potentially powerful enough to answer questions like "which women experience which side effects?" and "who should take estrogen and who should not?" As an individual person navigating the shoals of menopause, these are the questions that are most relevant.

This issue of Internal Medicine News reports on Dr. Richard Santen's conclusions as part of a task force from the Endocrine Society on hormone therapy. Apparently when one analyzes the subgroup of women in their early 50s and those within 10 years of menopause, a significant 30-40% reduction in overall mortality was seen in estrogen users, with or without progesterone. This is, of course, just the group of women who would be likely to want to use estrogen for treatment of the hot flashes, mood changes and sleep disorder so common in early menopause.

As a physician who sees many women as they experience the end of regular menstrual cycles along with the joys of waking up multiple times each night in puddles of sweat and being unable to remember what it was that they were supposed to be doing right now, I will again have to adjust my recommendations regarding the use of hormones. I will continue to struggle with answering questions about which forms of hormones are safest, how long to take those hormones, when and how to stop them. The WHI will be unable to answer many of these questions due to its study design. I will, however, have a new piece of information to support the women I treat who feel they really want to take estrogen.

Here is a link to the Internal Medicine News article.
http://www.internalmedicinenews.com/article

Gaming the new system?

2010-07-29T23:45:00.000-07:00

Last night I attended a program put on by the hospital about health care reform. The first speaker had clearly spent a great deal of personal time and energy working with folks who really didn't want the health care reform bill to pass. He had a good ole boy presentation style, peppered with sarcasm and full of predictions of imminent doom for the world as we now know it. The only saving graces for his talk were that the food was excellent and that he used so much insurance and benefits jargon that the majority of the audience quit listening to him.

The second guy was more balanced. He identified himself as a moderate republican, and though he didn't particularly like the health care bill as a whole, he presented a pretty balanced review, and looked at ways we could allow it to improve health care.

His major points included the fact that "accountable care organizations" (ACOs) are likely to become a dominant way to deliver health care, with their focus on coordinated care of patients from hospital to clinic to home. An ACO will consist of doctors, nurses, hospitals and supporting staff who will provide full spectrum health care for patients and be reimbursed based on the severity of the patients' illnesses and the quality of their care. Challenges for these organizations will be functioning in small communities and working out who gets what money for what job.

He addressed the idea that the bill would be repealed, and argued that it is extremely unlikely, even if the next administration is republican dominated, for that to happen. Many of the bill's early achievements will be so attractive to the majority of Americans, including expanded health care coverage for preventive services and to the uninsured or underinsured, as well as breaks for small business presently strapped by high health insurance costs, that dismantling the whole thing would be suicidally unpopular.

Apparently this second guy, a Washington lobbyist, will be working with our hospital to help us qualify for some of the grants available in the bill for organizations wanting to innovate in health care delivery. Many of these grants are particularly applicable to a small community such as ours, and could help us move in directions that we have discussed in the last year.

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

2010-06-29T15:21:00.000-07:00

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

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

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

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

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

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

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

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

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

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

CT scans--why not?

2010-06-23T18:24:00.000-07:00

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

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

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

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

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

The pseudoscience of medicine

2010-06-19T23:44:00.000-07:00

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

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

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

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

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

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

800 pound mooses and the American College of Physicians

2010-06-09T18:20:00.000-07:00

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

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

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

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

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

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

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

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

How Does Cuba Do It?

2010-05-18T15:09:00.001-07:00

Cuba has achieved a life expectancy approximately equivalent to the US, despite a long standing embargo on food and medical supplies and despite spending a small fraction of the amount of money per person on health care than we do.

A Stanford social sciences researcher, Paul Drain, has studied Cuba's medical system and has identified a few factors that may be responsible for their success. Cuba completely subsidizes medical training. After high school, students who are interested in medical school and qualify for it attend 6 years of combined college and medical training, complete with a stipend for living expenses and then 3 years of postrgraduate training in primary care medicine. Many do rural health residencies either before or after the postgraduate training. After becoming family practitioners, 35% of them do further specialty training and the rest remain primary care doctors. There are many multi-specialty clinics which provide care in cities, and small primary care clinics that serve small neighborhoods. Their vaccination rate is excellent as is their rate of professionally attended births. Everyone sees a doctor at least once a year and sometimes these are home visits. Doctors are not paid highly, but then they emerge from training without the usual multi-hundred thousand dollars of educational debt that they end up with in the US.

If one were to look at the economic incentives that have lead to our excessive health care expenses and our shortage of primary care doctors and effective preventive medicine, it is not hard to see how we have landed in our present circumstances. It is a bit harder to see how we should escape from them. Certainly subsidizing the training of primary care physicians would be a good start.

Paul Drain was interviewed for Wired, and published an article in the April 30 issue of Science magazine. This is a link to the Wired article.
http://www.wired.com/wiredscience/2010/04/cuban-health-lessons/