Thursday, February 23, 2017
Probiotics promote digestive health--is there a germ of truth
Several times each week, I am asked about the value of probiotics. Many of my patients are already on them, based on a personal recommendation or an advertisement. As a gastroenterologist, I routinely treat patients with all varieties of diarrhea conditions, such as irritable bowel disease, ulcerative colitis, Crohn's disease, lactose intolerance, celiac disease, and the highly feared gluten sensitivity. Many of them arrive in the office with a probiotic in hand waiting for me to pass judgment. These patients look to me as a Digestive Supreme Court Justice as they sit on the edge of their chairs waiting for my ruling in the case of Probiotics vs. Disease.
First, let's all be clear on what a probiotic is. Probiotics are bacteria that provide health benefits when consumed. Stop a moment and consider how bizarre this concept is. Physicians have been fighting germs since the days of Louis Pasteur. We have taught the public for generations how important personal hygiene is. We are counseled not to eat under-cooked food from fear of contracting a food borne illness. Every hospital in the country is stressing hand washing to all personnel to protect patients from infection. Many of us won't leave the house without a hand sanitizer bottle.
In other words, germs are bad, unless they are probiotics! In the latter case, billions of germs are deliberately ingested in order to relieve symptoms and treat diseases, an ironic shift in classic germ-fighting medical practice.
Hardly. Our intestines are filled with zillions of bacteria. Miraculously, during health these germs are not able to penetrate through the walls of intestines to reach internal organs which would cause a severe infection. These strains of bacteria within the bowel all live together in balance providing health benefits to us. They aid in digestion and immunity. Some of these germs create vitamin K, which we use to maintain a healthy clotting system.
When this bacterial neighborhood, which is called the intestinal biome, is disrupted, then disease can set in. For example, when we take antibiotics to attack “bad germs,” such as for a pneumonia or a urinary tract infection, the antibiotic also upsets the “good bacteria” within our intestines. In addition, many digestive diseases have an intestinal biome that is out of balance. When the biome isn't balanced, then the whole body is under a strain.
Here's the theory in simplified form. When the community of beneficial germs within our bowels is disrupted from antibiotics or disease, probiotics can get the biome back into balance. Scientists are not entirely sure how this happens, but probiotic research is in high gear to understand how they work and who should receive them. The theory is that bringing the biome back to its normal state restores health and relieves symptoms.
What do I tell my patients with digestive conditions regarding probiotics? I tell them the truth. The supportive science is rather thin, but many of my patients feel better on a probiotic program. We don't know precisely which probiotic works best for a specific patient or disease, or how often to dose them. Importantly, we believe that they are safe, but I would be very reluctant to recommend them to someone with compromised immunity.
If you have digestive symptoms and are contemplating a probiotic, here are 3 steps to consider:
• Open the jar.
• Open your mouth.
• Open your mind to the belief that these germs can heal you.
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.
3 pretty awesome things about the UK's National Health Service
Recently, I've been writing a lot about health care systems around the world and thinking about what an ideal system for America would look like. I've enjoyed reading the online responses—healthy debate is indeed a wonderful thing. I've said previously how out of all the systems I've experienced, the ideal probably resides somewhere in-between a completely socialized system and a private, free-market-insurance-based one. Australia comes pretty close to doing this, by encouraging people to buy their own insurance, but also having a public backup for those who need it. Despite growing up with the UK's National Health Service, and admiring it on many different levels, the fact remains that no other country in the world has copied this heavily centralized system. Yet, I can't say by any stretch of the imagination that it's not a hugely noble and fair concept with humanistic ideals. Lots of my closest family and friends rely on it and are very happy with their service. Here are 3 amazing things about the NHS:
1. No bills and no stress over expenses
No British citizen has to worry about ever seeing a medical bill or dealing with out-of-pocket costs. Emergency care is excellent and most urgent matters are dealt with in a timely manner. Those things that do incur charges, such as certain prescriptions, are capped at a very low level with plenty of exemptions. The majority of UK citizens would gladly sacrifice choice and put up with some waiting for non-urgent care, to keep this system in place.
2. Great selfless doctors
Doctors in the United Kingdom are among the most hard-working in the world and rarely choose a medical specialty because of how much they will earn (there's not much variation between what medical specialists are paid anyway). Granted, they have relatively low student debt (although that is changing), but are generally much more conservative and inclined to only do what's absolutely necessary. As a patient, you will never have the thought in your mind that your doctor is ordering a test or recommending a procedure because they want to make more money.
3. Fosters a sense of society
The fact that most of the British public sees their NHS as a national treasure, also reflects something else that is very different on both sides of the pond. In the UK, there is more of a concept of “society”, which naturally comes about in socialized systems. People in Britain generally have a feeling of “we are all in it together”, especially when it comes to the health service. Since its founding, America has generally been a more individualistic society which encourages freedom, choice and personal responsibility. The collective consumerist psyche in the United States would unlikely endear itself to socialized medicine anyway (and I'm not saying there's anything wrong with that, but merely stating an observation).
Every health care system in the world is currently facing its share of challenges due to a combination of expensive new treatments and aging populations. The NHS also has huge problems with physician and nurse shortages, low physician morale due to contractual disputes, and excessively long wait times for certain illnesses. But it would be disingenuous to suggest that it's all bad and anything other than the reality that many socialized health care systems are respected and loved by millions of their citizens. Can we really say the same here in the United States?
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Wednesday, February 22, 2017
The Affordable Care Act (aka Obamacare) on the chopping block
The Patient Protection and Affordable Care Act (ACA for short, or Obamacare as it has come to be known) was passed on March 23, 2010 after intense wrangling and many compromises. It is a huge and complex bill which changed health insurance costs and availability significantly, resulting in over 20 million Americans getting health insurance who were previously uninsured. Many people can now get health care without impoverishing themselves, but the bill is also not without significant and possibly fatal flaws.
What does it do?
The link here is to a blog I wrote in early 2010 after a grueling 5 hours of reading the bill that was eventually passed. The things people like about it include:
• Health insurance can be bought through “exchanges” which make it easy to compare plans and purchase insurance.
• The wording of policies has to be understandable for regular people.
• An insurance company can't refuse to cover a patient because of a pre-existing condition and insurance rates can't be hiked due to being in poor health.
• Adult children can remain on their parents' insurance until age 26.
• Insurance companies can't stop paying medical costs after a certain ceiling amount and can't kick someone off due to medical problems.
• Procedures considered to be effective prevention need to be covered 100%, without a deductible owed by the patient.
• Private health insurance is subsidized for people with low income and free insurance is available for people at even lower income through the Medicaid program in those states that have chosen that option. Nineteen of the fifty states, however, have opted out of expanded Medicaid.
• For most people buying health insurance through the exchanges, health insurance premiums will be affordable due to subsidies.
• There have been innovations designed to improve both cost and quality.
What's wrong with it?
• Although health insurance is more affordable for most people and now covers preventative services, it is also required. If the insurance companies have to agree to insure patients who are going to cost them lots of money, they also need to insure patients who won't cost lots of money or their costs will go up and they will no longer be able to make a profit. The requirement to buy health insurance is called the individual mandate and is enforced by a penalty charged on income tax of up to $695 for an individual who has not paid for insurance for a year. The amount of the fine is capped at the cost of the cheapest insurance available. The idea is that you can either pay and get insurance or pay and not get insurance. People don't like being told they have to buy health insurance, especially if they are well. Unfortunately for many of the insurance companies, healthy people did not purchase insurance despite penalties, so many of these insurance companies had to opt out of the exchanges because they lost money.
• The ACA was supposed to reduce costs overall. Obviously it wasn't going to cost less to get health care for many more people, but the overall trend was supposed to go in the right direction. This document from the Center for Medicare Services is interesting. Health care expenses as a percentage of our gross domestic product went up, from 17.4% in 2014 to 17.8% or $9,990 per person in 2015. The Congressional Budget Office predicted an overall reduction in costs. Perhaps it just needed more time.
• The government assured the insurance companies that it would pay them for any losses under the new plan. The total cost of this was expected to be minimal since insurance companies that did well would pay a portion of their profits to the program. There were more losses than expected, and the Republican dominated congress refused to fund the difference, leading to what was essentially a breach of contract. The stiffed insurance companies are now suing the federal government for billions of dollars. It turned out that health care cooperatives, which were a great idea, had the biggest trouble staying afloat and so the vast majority of those have folded.
• More patients can now receive health care, 20 million or more, but out of pocket expenses and the price of insurance is rising. Before subsidies, health insurance premiums will rise 25% in 2017. Premiums reached over $18,000 for an average family in 2016, though most families still were able to buy affordable policies through the exchanges because of subsidies.
• People receiving health insurance through their employers are spending increasing portions of their salaries for their share of health insurance premiums, now over 10%. Employers pay the majority of these premiums, leading to lower profits and lower worker salaries. This is a continuation of a trend that was present before the ACA passed, but the situation has not improved.
• Twenty-nine million people are still uninsured. Nineteen states have refused to expand Medicaid. This leaves patients who are too poor to afford health insurance but not poor enough to qualify for regular Medicaid with no health insurance. These people get medical care only in extreme circumstances or pay for expensive care themselves, leading to financial destitution and unpaid bills which hospitals or clinics have to absorb.
• Some of the experiments to improve quality and reduce costs have introduced layers of complexity to doctors' already complex jobs and this leaves them with less time to spend with patients and with more job dissatisfaction. Physician burnout is increasing, now at over 50%, primarily attributed to administrative duties.
Could the ACA be better?
Yes, for sure. There were many compromises leading up to passage of the bill, despite the fact that in the end it passed without any Republican support. Progressives pushed for a single payer system which would make the federal government the major provider of health care coverage. (Actually, in terms of dollars spent, the federal government is the major provider of health care coverage.) This could have been done as an expansion of Medicare which is already an established and relatively frugal insurance plan. The government would then have been in competition with the health insurance industry which did not make their very powerful lobby happy, and some physicians balked, expecting a heavy handed approach to what they were allowed to do for their patients. A “public option” was also put forward, which could have provided an optional government funded insurance, but that, too was seen as competing with private insurers and might have become yet another very expensive and possibly budget busting entitlement program. The ACA legislated the creation of the Center for Medicare and Medicaid Innovation to help come up with creative ways to provide and pay for health care, but prevented them from using cost-effectiveness analysis to decide what to recommend. This was because of concerns about “rationing” health care. The ACA in its original form required the states to expand Medicaid, with the federal government footing all of that cost for 2 years and then gradually reducing that subsidy to 90% by 2020. The Supreme Court found that requirement to be unconstitutional, leaving 19 states to make a short sighted decision to forego a significant subsidy from the federal government and leave a proportion of their poorer citizens without health care coverage.
So the ACA could be better by being bigger. It could have entirely revamped how health care was paid for by introducing a single payer or provided a good public option. This would not have passed congress and certainly won't now. It might have been great eventually, but would have been very expensive and might have destabilized the economy. The ACA could have explicitly recommended we reduce costs by looking at value and eliminating services with low value. It could have offered expanded Medicaid without state support, leading to more nearly universal health coverage.
It could have been better by having bipartisan support, but, having watched the whole process go down, it's not clear how that could have happened. The idea of universal coverage with an individual mandate was taken straight from various Republican proposals over the last 15 years, and looked very much like the Massachusetts health plan sponsored by Mitt Romney. The ACA did not fund abortion and did not extend Medicaid to illegal immigrants. It provided a waiver for patients based on religious beliefs. There was no funding for talking about end of life wishes with patients due to concern that this might mean we had created “death panels” to decide who would live or die. Still, there was no Republican support for what was very appeasing legislation.
It could have been better by being smaller. Many of the exclusions and exciting new programs which were introduced to make it attractive to legislators also made it hard to understand. Patients to this day have very little idea what the ACA is or even that it is the same thing as what they call Obamacare. Physicians are unclear about its provisions and blame various woes on the ACA that belong to different legislation or to developments not related to law at all.
What will happen to it?
Members of the present administration have vowed to repeal it, but want to hold on to some of the most popular provisions. I have gleaned from many reliable sources that:
• They would like to make health insurance companies continue to insure people regardless of pre-existing conditions so long as they maintain continuous health care coverage. They also want to allow children to stay on their parents' health plans until age 26.
• They do not want to continue to subsidize the expansion of Medicaid or subsidize insurance for people based on income. They would consider a refundable tax credit to help pay for insurance.
• They would like to limit the federal government's funding of Medicaid. Presently the federal government pays a percentage of each state's costs for Medicaid and has significant control over how that money is spent. The Republicans in power favor “block grants” for Medicaid which would provide a fixed amount of money for the program to each state, to be spent as the state decides. This could lead to appropriate economies, but could also lead to states running out of money for programs and cutting funding to vulnerable people.
• There has been a proposal to reform malpractice at the federal level, primarily capping what a plaintiff can receive for non-economic damages. This would save money, in theory, by encouraging physicians not to order excessive tests just to avoid being sued. Thirty states have already passed such legislation and some evidence does point to a reduction in health care costs.
• Health Savings Accounts (HSA) would play a part in paying for care, allowing patients to use pre-tax dollars for health expenses. Unfortunately most of the people who have bought insurance through the exchanges are not wealthy and have been subsidized, and so don't have money to put into HSAs.
• It is unclear what the administration intends to do with regulations on the insurance industry. If they require that insurance companies insure patients with pre-existing conditions who will likely be more expensive, but repeal the individual mandate as they have promised to do, insurance companies might well fail. Patients have become used to getting preventative care without having to pay a deductible, but it is unclear that this is cost saving, so without legislation to require coverage insurance companies may do away with this provision. This is likely to make constituents very unhappy. I have not heard anything about caps on out of pocket expenses or lifetime expenditures.
• There is an intention to allow insurance companies to sell their products across state lines, improving competition and therefore reducing costs. This may help, but patients may find that their cheaper out of state insurance doesn't pay for their local doctor or pharmacy or that it lacks protections they had come to rely on.
There is a good chance that the “Obamacare” that we are just getting used to will go away. This will be “the beginning of an uncertain and tumultuous chapter in U.S. health policy” per Jonathan Oberlander, a professor at University of North Carolina and the author of The Political Life of Medicare, in an article in a recent issue of the New England Journal of Medicine. The ACA has been divisive and irksome to Republicans for years and they would have repealed it already if they had had the political muscle they do now. It will be tremendously difficult to deal with the aftermath of that, especially the 20 million people whose access to health care will be endangered or lost. None of the ideas that have been mentioned so far come close to managing this. In order to provide access to care that constituents demand at a price that taxpayers can tolerate, compromises will need to be made. The work of improving cost efficiency in medical care, pharmaceuticals and in payment models will need to become a non-partisan issue.
*As a person in need of health care, it may be wise to sign up for health insurance through the marketplace before the Jan. 31 deadline, if you are not already insured. The future of these insurance policies is unclear, but it is unlikely that any change in the ACA will affect insurance that a person has already purchased, at least in the short term.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Tuesday, February 21, 2017
A new textbook on health systems science
Many aspects of academic medicine, from the structure of the medical school curriculum to the organization of departments in schools of medicine, are neatly segregated into two buckets: basic science and clinical science. In the jargon of medical schools and education, basic science refers to the basic biomedical sciences that have traditionally been taught in the first two years of medical school, such as anatomy, physiology, biochemistry, and pharmacology. While plenty of clinical material has migrated into the first two years of medical school over the years, such as learning to interact professionally with patients and perform a physical examination, the main focus of the first half of medical school has historically been on basic science, culminating in the U.S. Medical Education Licensure Examination (USMLE) Step 1 exam.
Once students finish their basic science years, they move on to the clinical sciences, where they begin rotations, also called clerkships or clinical experiences. They usually first rotate through the core medical specialties, i.e., internal medicine, surgery, pediatrics, obstetrics/gynecology, and psychiatry. This is then followed by rotations in other specialties and subspecialties, ultimately leading to graduation and the start of their residency training.
This division of medical education goes beyond just the medical school curriculum. The organizational structure in most medical schools is to group academic departments into basic science and clinical departments. These two types of departments usually have different funding models. Basic science departments are usually funded by base budgets for teaching and grants for research, with an expectation that just about all faculty have research grant funding. Clinical departments have base budgets and research programs as well, but they perform another activity, which is clinical care that provides practice opportunities (and revenues) for faculty and learning experiences for students, residents, and fellows. In many clinical departments in medical schools, research activity is modest and may be partially subsidized by the margins from clinical revenues.
The focus on these two groups of sciences takes the perspective of the physician taking care of a single patient, i.e., applying the best biomedical science through the lens of a specific clinical specialty. However, despite its primacy, there is more to the practice of medicine than taking care of single patients. Physicians and other clinicians work in a healthcare system that has other concerns, such as continually increasing costs, worries about patient safety, and questions about the quality of care delivered. As such, 21st century clinicians must be competent in more than the diagnosis and treatment of disease in individual patients. This has led to emergence of the notion of a “third science” of medicine, which focuses on how to optimally provide healthcare for patients and populations. While some describe this as “healthcare delivery science” (my preference) or “implementation science,” the emerging name, as given to a textbook in this area, is now “health systems science.”
The textbook is published by the American Medical Association (AMA), which has been supporting innovation in medical education through its Accelerating Change in Education (ACE) consortium, funded by grants to medical schools . OHSU was one of the original grantees in this program to establish “medical schools of the future.” I have been pleased that one outcome of this program has been the expansion of instruction in clinical informatics for medical students, which I consider to be an essential competency for 21st century physicians .
The titles of the chapters of the new textbook describe the important topics covered by health systems science:
1. Health Systems Science in Medical Education
2. What Is Health Systems Science? Building an Integrated Vision
3. The Health Care Delivery System
4. Value in Health Care
5. Patient Safety
6. Quality Improvement
7. Principles of Teamwork and Team Science
8. Leadership in Health Care
9. Clinical Informatics
10. Population Health
11. Socio-Ecologic Determinants of Health
12. Health Care Policy and Economics
13. Application of Foundational Skills to Health Systems Science
14. The Use of Assessment to Support Learning and Improvement in Health Systems Science
15. The Future of Health Systems Science
I am delighted myself to be the lead author of one of the chapters, not surprisingly the one on clinical informatics . I hope this chapter will introduce many new generations of medical and other health professions students to the informatics field and its role in healthcare delivery. Of course, informatics plays many roles beyond healthcare delivery, such as informing the care of individual patients and facilitating all types of research, but the effective use of data and informatics is a key aspect of health systems science.
I hope that this new textbook will lead the way in emphasizing the importance of health systems science in the work of physicians and other healthcare professionals. Clinicians have long known that diagnosing and treating disease, while the centerpiece of medical practice, cannot be carried out in a vacuum outside the realm of the patient's and larger health system's context. The care delivered to those individual patients will be better if the clinician has the perspective of that larger system.
1. Skochelak, SE, Hawkins, RE, et al., Eds. (2017). Health Systems Science. New York, NY, Elsevier.
2. Hersh, WR, Gorman, PN, et al. (2014). Beyond information retrieval and EHR use: competencies in clinical informatics for medical education. Advances in Medical Education and Practice. 5: 205-212. www.dovepress.com/beyond-information-retrieval-and-electronic-health-record-use-competen-peer-reviewed-article-AMEP.
3. Hersh, W and Ehrenfeld, J (2017). Clinical Informatics. in Health Systems Science. S. Skochelak, R. Hawkins, L. Lawson et al. New York, NY, Elsevier: 105-116.
This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.
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- Probiotics promote digestive health--is there a ge...
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Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
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David Katz, MD
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Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.