ACP Internist Blog

Monday, February 18, 2019

Blockchain as a medical innovation

First there was Bitcoin, a cryptocurrency that utilizes blockchain, a decentralized system of data collection and transactions that we are told will defy hacking. (Wasn't the Titanic said to be unsinkable?) We read that cryptocurrency and other blockchain functions will be a societal game changer, much like the internet was when Al Gore invented it some years ago.

My own state of Ohio will now accept Bitcoin as payment for commercial taxes.

And, of course, there are many other cryptocurrencies mushrooming around us. In my life, many innovations seem to be solutions in search of problems. I don't find my current methods of transacting business, cash and credit cards, to be so onerous that I am screaming for a new way to conduct commerce. But, I will admit that I have security concerns about my credit card number and other highly personal data being “safely stored” all over the internet. Some years ago, I enjoyed the thrill of being a victim of identity theft, which in gastrointestinal terms, is about as pleasurable as a rigid sigmoidoscopy. Just contacting the three credit agencies in the quest to reach living breathing human beings is a task that separates the weak from the robust.

Northeast Ohio is prepared to invest over $100 million to attract and cultivate blockchain investors. Will this create a Blockchain Bubble? We will see. Initial investors in Bitcoin hit the jackpot. But for many others who didn't time their investments at a propitious moment, they lost big.

There are many aspects of our personal and professional lives that could utilize blockchain. And, like any new innovation, we don't have to understand it to benefit from it. Do we really know how our routers at home work? Of course, whenever a new disruption breaks in on the scene, many existing businesses and organizations will be threatened. Consider Amazon, the Mother of All Disrupters. Bitcoin, for example, could assume many functions of traditional banks and perform them better, more securely and at less cost. If cryptocurrency can really deliver, then those under threat will have to adapt or they will be run over. Those players who are not adaptable will become obsolete. Typewriter repair is no longer an occupation.

In my own profession, blockchain could offer incredible benefits. As a physician, the notion that I could easily access all of a patient's medical data from my office would be a game changer. And, every new medical event would be instantly and securely added to a blockchain. The HIPAA police would become unemployed, another blockchain casualty. Imagine how this would affect medical care in an emergency department. Physicians, with access to the entire record, would be less likely to order medical tests if they could determine that they had already been done elsewhere. And, beyond the medical advantages, I'm sure the billers, coders, and insurance companies would also be hitching rides on the Blockchain Express.

Patients and I today are often frustrated that even in our digital era, I do not have easy access to their electronic records, which often exist in different medical systems and institutions. Wasn't electronic medical records supposed to solve this?

Will blockchain become the coin of the medical realm? Has this post induced you to invest in cryptocurrency? My advice? Buy a CD instead. But, stay tuned.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Friday, February 15, 2019

The one simple reason physicians lost control over their profession

I recently met an old friend of mine for the evening in New York City. He's a talented young orthopedic surgeon, who has already, in the short amount of time since finishing residency, experienced so many of the problems our health care system faces. The topic of conversation quickly turned to the current state of medical practice, the dramatic swing to corporate medicine, and the consequential loss of autonomy suffered by physicians as a result.

I asked him what his views were on why doctors appear to have lost control over their profession. He said something very profound: “Oh there's a simple reason for that Suneel: It's because doctors don't get along”. That was his single one-sentence summary. He then expanded on how he believed that as a group (considering there are close to a million physicians in America), they could have immense collective power and advocacy. But because we are so fragmented with our own selfish interests, we exponentially diminish any power we have. He went on: “An orthopedic surgeon doesn't really care about what's happening to an internist, and vice versa too. We are all solely focused on our own area of practice, work environment, and income. There's far too many big egos running around, and what's worse is that doctors frequently fight with each other as well”. All the while, our health care system continues to decline and patients bear the brunt.

I thought that was so true and haven't ever considered it in such simple terms before. My mind turned to how this could actually be a story of a million-and-one scenarios in life: a divided house always falls. And that always leaves the door open for a third party to come in and take advantage. I actually started thinking about another story that I grew up with. Being of Indian descent, for some reason the story of British rule of India came racing to my mind (albeit on a much larger scale with bigger consequences). India was a land of princely Kingdoms back in the middle of the last millennium, unable to get along with each other. Of course, it was a dog eat dog world back then, and might was right. Whoever was the strongest with the mightiest armies took control.

In came the British with their East India trading company, initially under the rule of Queen Elizabeth 1st in the 17th century. To cut a long story short, the British cleverly exploited the divisions for their own good, implementing a classic “divide and rule” policy. In a relatively short amount of time, they had gone from trading a small amount, to gaining complete control over a massive country—while forming “deals” with complacent local ruling Maharajas to keep them “comfortable” (inevitably these Maharajas would realize that perhaps the deals were not worth the loss of control and autonomy, and that they had been played by an entity that viewed them solely as a commodity, but this would come too late).

I am of course giving a very simple account here, for the purposes of this article—but the broad theme is the one to grasp. To be honest, who could blame the British in the world as it was back then for cleverly doing this. Nearly every king and country was at it, if they had the means to do so, to expand their power and gain wealth (as an Indian, part of me is actually grateful it was the Brits with their relative fairness rather than a more brutal and murderous force like Imperial Japan or Nazi Germany).

Perhaps there's also an argument to be made that India would have even fallen apart on its own, had the Brits not come in at that point in history—but that's another story. One can never view historical stories through the lens of today's standards. Thankfully the world progressed, and India was able to gain the self-rule that any group of people or country must have. But it took a few hundred years unfortunately, after their divisions had been exploited by an external entity for their own benefit, while millions of impoverished Indians had suffered a complete lack of progress.

The story of how the British Empire took over India, is one of the most classic large-scale examples I can recall of a 3rd party cleverly taking advantage of a divided house. I encourage anyone to read the fascinating history in more detail. This timeless scenario plays out everywhere every day, from your own individual home, community, business, right up to a national level. It's a timeless tale.

But back to health care—I'm just sad it happened to doctors too.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, February 14, 2019

Sad state of American hearts

My lament is literal, not figurative. As a humanist, I might well have cause to lament the figurative state of the American heart, too: the roiling churn of diverse “isms” that are the new normal, disfiguring and pockmarking the ideals and values a big-hearted land of inclusiveness has long beamed to the world. But my lament is literal. To paraphrase an NBC News headline that stated the case bluntly: almost half of all Americans have heart disease.

So, my fellow Americans: feel that thump in your chest? Now, flip a coin. You are in one camp or the other.

Actually, I think the situation is quite a bit worse than that. The statistics in play here refer only to adults, and thus ignore the earlier, inchoate versions of all the same risks in our children. They refer only to overt evidence of cardiovascular disease, not to the risk factors for risk factors that are on plain display long prior.

Do a more expansive version of much the same math, in other words, and the conclusion is far bleaker. If you are an American adult, and have a heart, either it is in some state of sad peril, or you and your vitality are the anomaly- consigned to the enviable region of rounding error. Nice to have a bit of company there.

The statistics in question come from a report entitled Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association, published Jan. 31 in Circulation. As detailed in the full report, the work represents a year-long effort by a multidisciplinary group of experts with the American Heart Association, the National Institutes of Health, and other government agencies to compile and disclose the most current data on heart disease, stroke, and cardiovascular risk factors in the U.S.

As implied by the NBC News headline, and others just like it, the salient implication is an increase in the prevalence of cardiovascular disease over recent years, and a related increase, albeit modest, in cardiovascular deaths.

Let that sink in for a moment. In this age of emergency angioplasty and drug-eluting stents; of newly devised bioengineered agents to inhibit platelets and lower lipids; of robotic surgery, and CT-based calcium scoring, cardiovascular deaths have gone up.

We in preventive and lifestyle medicine have long noted that despite the profound limitations of modern medicine with regard to promoting health or vitality, it is astonishingly good at forestalling death. That is the very reason we have so much “chronic” disease; what used to kill us now meets its match in the CCU or ICU. The result is generally a stalemate: the disease and treatment go on together, for years or even decades.

In that context, even a slight rise in cardiovascular death is truly startling, and alarming.

Such alarm bespeaks high drama, and indeed, I believe this report, running to 473 pages and covering the Heart Association's check list known as Life's Simple 7 (smoking, physical activity, diet, weight, cholesterol, blood pressure, and glucose control) as well as sleep and other topics notable for including social determinants of health, signifies just that. But before affirming the drama, and exploring the implications of it, there is one welcome reason to dial it down a notch.

As noted prominently in much of the media coverage of the AHA report, the definition of high blood pressure was altered between this report and the last. The threshold was formerly set at 140/90, but has been revised down to 130/80. As a result, millions of Americans who didn't meet criteria for high blood pressure before, now do. This is not a change in actual condition; it is a change in catalouging. We saw just such an overnight bump in the prevalence of obesity years ago when that definition was revised.

But while there is an argument there for mitigating our alarm, the counter-argument is rather robust as well. The definition of high blood pressure, or “hypertension,” was not revised downward without reason. The most recent evidence suggests that what was once considered the high-normal range of blood pressure is associated not only with increased risk of heart attack and stroke, but with dementia as well. The new approach to cataloguing BP is well justified. Stated differently: we are not over-diagnosing cardiovascular disease now; we were under-diagnosing it all along. The wake-up alarm stands.

So, let's concede without reservation, this is dramatic. Gather in any room with adult friends, family, co-workers, or strangers for that matter. A cinema; supermarket; church, temple, or mosque; the bank; a school; a party; shopping mall or football stadium. Look around. Half of everyone there has some form of cardiovascular disease and will suffer chronic infirmity, premature death, or both as a result of it. Look in the mirror, too- because you could well be with that half.

That, though, is not the claim to drama here. The true claim to drama is that almost none of this disease needs to happen. Almost none.

More than a quarter century ago, a report on much the same topic- chronic disease and premature death in America- made clear that 80% or more of it all could be eliminated simply by not smoking, being active, and eating reasonably well. With attention to the full list of “root causes” of premature death, even more of it could be eradicated. In the years since, that message has only ever been reaffirmed in the peer-reviewed literature. Populations like the Blue Zones, and the Tsimane, show us that cardiovascular disease does not need to happen as we age- a profound insight that first inspired the inimitable efforts of Ancel Keys. The experience in North Karelia, Finland, shows that what we know about the prevention of heart disease by lifestyle means can be introduced and made to work in beleaguered populations- like our own.

Roughly half of us all- meaning half of you reading this now- have cardiovascular disease in one form or another, whether you know it yet or not. Many in the other half have earlier versions of all the same risk factors, and will trade camps in the fullness of time. This is the sad state of cardiovascular health in America now. It is increasingly the sad state of the modern world as well.

But let us take heart, not lose it, over this provocation. We have long known how to leverage lifestyle to eradicate this scourge. Knowledge is power the moment we decide to translate what we have long known into what we routinely do. This report is simply a reminder that now would not be too soon.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his Linked In page.
Friday, February 8, 2019

Wallet X-ray

Have you ever heard the term “wallet biopsy“?

A wallet biopsy is what occurs in U.S. health care when you or a loved one show up with a medical complaint to seek treatment.

From the emergency department to the inpatient hospital, to the doctor's office or the procedure suite—at any location where an American might receive health care, you're subject to a wallet biopsy.

Health care is a business. An expensive one. And the beast has to be fed—not only to keep the lights on, but also to buy the latest equipment and pay the folks that provide the care.

In a recent piece for Kaiser Health News, journalist Phil Galewitz updates us on how the U.S. practice of wallet biopsy has morphed into wallet X-ray.

The idea is longstanding: grateful patients (with financial means) have always looked for ways to share their good fortune with the medical establishments (and professionals) that have treated them.

Galewitz’ piece suggests that the practice of seeking out potential donors has ramped up in intensity: Large health care enterprises (often university-based or affiliated) are performing financial background checks on patients they deem to be potential donors—and then aggressively wooing them.

There's nothing necessarily wrong with this—it just smells a bit fishy. And it implies that if you're not a grateful patient, or in financial position to be one, that you may wind up getting a bit less … er, attention? Fewer amenities? Less TLC?

Check out the article, which also ran in the New York Times, and let us know what you think of the specialty of wallet radiology.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience. He also hosts StudioTulsa: Medical Monday for Public Radio Tulsa.