Friday, February 26, 2010

How Much Does Technology Improve Health?

This post by Jonathan LaPook, ACP Member, originally appeared at Better Health.

Last week's CDC report, Health, United States, 2009 confirms that Americans are increasingly turning to medications, scans, and procedures to improve their health. Exercising, eating right and weight loss: not so much.

Watch Dr. LaPook online

Don't get me wrong. I love technology as much as the next guy--maybe more. I'm writing this on a laptop while jetting from California to New York. My iPhone, Blackberry, and Kindle are all within 10 feet of me. But my inner Luddite is starting to stir.

Here are the good news and bad news about three major findings of the CDC report:

1) The use of imaging studies like CT and MRI scans has tripled in the past 10 years.

The good news
These tests can be truly lifesaving. They can diagnose conditions like appendicitis and cancer much earlier than in the past.

The bad news
They're expensive and carry risks. The annual price tag for all these scans is about $100 billion and about 35% to 40% are estimated to be unnecessary. Experts are concerned that radiation exposure from tests like CT scans might increase the risk of cancer. And false positives often lead to further testing.

2) The percentage of Americans taking at least one prescription drug increased from 38% in 1988-1994 to 47% in 2003-2006. Those taking three or more drugs increased from 11% to 21%.

The good news
Medications clearly help control many medical problems, for example, hypertension, high cholesterol and diabetes.

The bad news
The more pills you take, including vitamins, minerals, and herbs, the greater the risk of an adverse interaction. Just three months ago, the FDA warned that commonly-used medications such as Prilosec and Nexium can make the anti-clotting drug Plavix less effective.

And medications can give patients a false sense of security. No matter how much Lipitor you take, you're not safe from heart disease if you eat a lousy diet, never exercise, and are obese.

3) Procedures such as angioplasty (opening up a blocked artery supplying the heart) and joint replacements are skyrocketing.

The good news
Used wisely, procedures are a tremendous boon. Emergency angioplasty performed during a heart attack saves lives. Knee and hip replacements can keep people active who otherwise would become immobile.

The bad news
About 30 percent of elective procedures are unnecessary, according to experts like Dr. Elliott Fisher, director of population health and policy at the Dartmouth Institute for Health Policy and Clinical Practice. Dr. Fisher advises, "If I were a patient, I'd ask two questions: help me understand the risks and benefits of these procedures, and by the way doctor, do you have a financial interest in ordering this test?"

To try to put the CDC report in perspective, I spoke to Dr. Linda Fried, Dean of the Mailman School of Public Health at Columbia University. She explained that despite advances in many areas over the past decade, we are falling way short in providing adequate healthcare to Americans. A big reason: We lack a public health system that emphasizes prevention.

She told me, "In our fast paced society, which goes for silver bullets, quick fixes, high return on investment on quarterly reports, prevention is not part of that scenario because prevention's for all of our lives, for our whole lives. And if we're successful in prevention, we don't see anything different and that is a mindset change which we need to learn to live with." She added, "Eighty percent of health is created through prevention and public health. Three percent of our (health care) dollars go into that. We need to find a better balance."

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Coming down from the summit

Thursday's health care reform summit reflected in six hours much of the past two years of discussions about health care reform. Starting with rebukes over the previous presidential campaign, the meeting resembled a more civil version of last summer's rowdy town hall meetings, and certainly reflected and reverberated recent months of congressional wrangling. (Los Angeles Times, NPR)

Despite talk of common ground, with no traction gained yesterday among Republicans, Democrats may try again to act on their own. (New York Times, Los Angeles Times)

Optimists says the summit could still have some positive impact: adding urgency, stressing nine common points between the parties, and adding fresh ideas. (Health Leaders Media)
Thursday, February 25, 2010

The Evidence for Colonoscopies as a Cancer Screening Test

This post by Harriet Hall, MD, originally appeared at Better Health.

Everybody knows that colonoscopy is the best test to screen for colorectal cancer and that colonoscopies save lives. Everybody may be wrong. Colonoscopy is increasingly viewed as the gold standard for colorectal cancer screening, but its reputation is not based on solid evidence. In reality, it is not yet known for certain whether colonoscopy can help reduce the number of deaths from colorectal cancer. Screening with fecal occult blood testing (FOBT) and flexible sigmoidoscopy are supported by better evidence, but questions remain. It seems our zeal for screening tests has outstripped the evidence.

Statistics show that the lifetime risk for an adult American to develop colorectal cancer is approximately 6%. Colorectal cancer is the second leading cause of cancer deaths in the U.S. In the U.S. there are currently 146,970 new cases and 50,630 deaths each year. Between 1973 and 1995, mortality from colorectal cancer declined by 20.5%, and incidence declined by 7.4% in the U.S.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years.

The American Cancer Society divides the available tests into these two categories and makes these recommendations for frequency of testing:

Tests that find polyps and cancer
--flexible sigmoidoscopy every 5 years
--colonoscopy every 10 years
--double contrast barium enema every 5 years
--CT colonography (virtual colonoscopy) every 5 years

Tests that mainly find cancer
--fecal occult blood test (FOBT) every year
--fecal immunochemical test (FIT) every year
--stool DNA test (sDNA), interval uncertain

Screening by colonoscopy seems to make more sense than other screening methods, because you can actually see the entire inside of the colon. Colon cancer is preceded by polyps and adenomas that progress to cancer. When a polyp is seen, it can be removed during the procedure. In this study, colonoscopic polypectomy resulted in a lower than expected incidence of colorectal cancer. But other studies suggest that the progression to cancer is not a steady process, and that adenomas may regress.

There is good evidence here and here that any benefit of colonoscopy is restricted to left-sided colon cancers, with no impact on right-sided colon cancer; we don't understand why. Some possible explanations are discussed here.

There are pros and cons to each of the different screening tests. Barium enemas and CT virtual colonoscopy involve significant doses of radiation. Colonoscopy only needs to be done every 10 years, but it involves an uncomfortable bowel prep, requires sedation, can cause serious complications like bowel perforation, and is unacceptable to some patients. FOBT screening is painless and harmless but has a lot of false positives and requires annual testing. Getting patients to come back every year for FOBT is problematic. Compliance and cost must be considered. Colonoscopy is expensive and there are not enough colonoscopists to screen everyone.

Apart from all those peripheral considerations, what do we know about the bottom line: the ability of each screening method to prevent deaths from colon cancer? According to the National Cancer Institute,

--Studies have shown that FOBT, when performed every 1 to 2 years in people ages 50 to 80, can help reduce the number of deaths due to colorectal cancer by 15 to 33%.
--Studies suggest that regular screening with sigmoidoscopy after age 50 can help reduce the number of deaths from colorectal cancer, perhaps by as much as 50%, but the quality of evidence is not as good as for FOBT.
--It is not yet known for certain whether colonoscopy can help reduce the number of deaths from colorectal cancer.

No randomized controlled trials have tested whether colonoscopy reduces the incidence of colorectal cancer. Support for the role of colonoscopy in colorectal cancer prevention derives from indirect evidence and observational studies.

There is an excellent review of all the pertinent studies here. Even though studies show that screening can reduce disease-specific mortality from colorectal cancer, there is little evidence that it reduces all-cause mortality. So as far as we know, screening probably won't prolong your life. It seems like it should: I don't understand why it doesn't, and it bothers me. This certainly isn't the message we're getting from the media and from the medical profession.

I'm guessing that if the appropriate studies were done and the technique of colonoscopy were optimized, a reduction in colon cancer deaths would be demonstrated. I'm guessing that colonoscopy would detect more cancers and precancerous lesions than FOBT or sigmoidoscopy, but I'm wondering whether the benefits of colonoscopy would outweigh the additional cost and risks compared to other screening methods. And I'm disturbed that a reduction in all-cause mortality has not yet been clearly shown for any screening method. We need more research to help us understand these issues.

Pending better evidence, I support the current USPSTF recommendations. I think patients should be told the pros and cons and choose which screening test they prefer. I have chosen annual FOBT for myself.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Can't they wait until it's over to complain?

The health care reform summit between party leaders hadn't yet started when the morning papers rolled out, calling for low expectations and fall-back positions. But one can't blame the pundits and politicians, who have measured the national mood on the subject. (Boston Globe, Wall Street Journal, USAToday)

H1N1 influenza
H1N1 has not peaked globally, according to the World Health Organization. (Reuters)

In case you missed it ...
Yet another take on practice management has emerged, combining its own elements of the patient-centered medical home and electronic medical records. It's been dubbed the E*TRADE of medical care, putting the patient in charge. One might call it another twist on concierge care; there's a $595 retainer fee once the practice exists its start-up phase. But it promises doctors patient panels of 900, no more than 12 patient visits a day and continual care instead of episodic visits. (Health Data Management)
Wednesday, February 24, 2010

Here We Go Again

This post by Steven Simmons, MD, originally appeared at Better Health.

I don't know if I can do it this time. A month ago, when it appeared that Congress had backed out of passing health care reform legislation, I felt neither happy nor sad. I didn't know how I felt but this past Monday, after the following triad of events had unfolded, it became clear to me that I feel weary towards the whole health care reform process:
--First, several states temporarily halted a rapacious rise in health insurance premiums from companies with quarterly profits last year in the billions of dollars. Seriously, don't these companies have PR firms?
--Second, the Senate Finance Committee actually issued a drug warning and in this one act illuminated either a glaring problem with Congress or, far more concerning and unfortunately for us, more likely in this instance, some type of bias at the FDA.
--Third, the President called for a televised debate on health care between "both sides." Then, within days, he posted his own plan on the White House Web site. It is a 10-page summary I found hard to follow and that left me with a troubling sense of deja-vu.

Last summer I studied the President's speeches and followed the White House Web site looking for his plan on health care reform. I plastered the walls of my home office with color-coded poster boards seeking to discover the President's plan as I was spurred on by the media's persistent use of the term, "Obama's Health Care Plan." One day, I stopped my search after reading an interview with Rahm Emanuel in which he confided that the administration had decided against having an actual plan since discussion would turn towards criticizing it. Instead, the Administration planned to focus their efforts on supporting Congress. Yet the poster boards remained up, until the third or fourth time my wife asked me to take them down. Apparently, I was already weary then.

But I wonder: Will this time be different ... or not? It started admirably with a call for debate, and this time the White House has presented an actual plan. However, something seems ominously similar since the President has based his plan, in large part, on the supposedly defunct legislation of a month ago, a bill that is a thousand pages longer than the Bible and authored in a fashion much like a quilt-party from yesteryear.

I am left with the image of doctors, patients, politicians, insurance administrators and the lay press all looking at our health care system as one would a sick patient. We agree that the patient is ill, but continue to disagree on the treatment. I would prefer it if our disagreements were based on the diagnosis, i.e. the reasons health care needs to be reformed. However, an accurate diagnosis eludes us all, as many of the signs and symptoms exhibited by our sick metaphorical patient are glossed over. Symptoms include a growing shortage in primary care doctors, out-of-control malpractice premiums, onerous rules and regulations with more sure to follow, and now, conflicting advice on drug safety as the Senate is accusing the FDA of either bias or incompetence by issuing their own recommendations on drug safety in regard to Avandia.

So, I will struggle against my weariness and strive to watch the debate on Thursday in good faith despite my fears of what is to follow. I hope we bear witness to an honest discussion that sheds light on what is wrong with today's health care system because I believe this is the only way to meaningful and working "reform."

We can't afford to ignore this debate or more unbelievable events are to follow. The Senate Finance Committee just passed along medical advice; what's next? Maybe the House Ways and Means committee will determine which finger I should stick ... well never mind... I'll just watch the debate.

Until next week, I remain yours in primary care,
Steve Simmons, MD

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--Amid Summit Fight's Eve

ACP Internist takes a literary look at tomorrow's anticipated health care summit between Congress and the White House. Shakespeare's A Midsummer Night's Dream follows the misadventures of two couples entering an enchanted wood; likewise, Democrats and Republicans enter into tomorrow's six-hour talk thinking puckish thoughts about each other.

A Midsummer Night's Dream by swamp dragon via FlickrThe summit is just political theater, so staging is everything. The audiences are important. Lights, camera, inaction! (AP, Politico, New York Times)

Democrats are talking as if they can revive health care reform from its dreamy slumber, possibly using reconciliation as a procedural maneuver. To paraphrase The Bard, "The course of true reform never did run smooth." (Los Angeles Times, NPR)

Primary care shortage
Primary care physicians have cut their average hours per week, citing low pay and worse work-life balance. Average work hours have fallen from 55 to 51 hours per week between 1996 and 2008, according to JAMA, or 36,000 doctors in a decade. But the doctors say cutting back will extend their careers overall. (Washington Post)

H1N1 influenza
Flu experts at the World Health Organization met to decide whether the H1N1 pandemic has peaked for this year. They did recommend that the next seasonal flu vaccine should include H1N1. Danielle Ofri, FACP, explained that the pandemic's toll had as much of an emotional impact on her patients as it did on their physical health. (AP, Reuters, CNN)

In case you missed it ...
The Food and Drug Administration and National Institutes of Health will collaborate on a bench-to-bedside process to speed how quickly basic research becomes medical treatments. A Joint Leadership Council between the two agencies will ensure regulatory considerations are part of biomedical research, and that the latest science is integrated into regulatory reviews. FDA Commissioner Margaret A. Hamburg, FACP, announced, "We are working in collaboration with the best minds and research institutions available, so that we can better develop and utilize new tools, standards and approaches needed to properly assess the safety, effectiveness and quality of products currently in development or already on the market."
Tuesday, February 23, 2010

QD: News Every Day--counting down to Thursday's summit

ACP Internist continues its look at Thursday's pending health care summit. The White House released its vision of health care reform yesterday to build party unity. But it drew immediate attack by the opposition. (ACP Internist, USAToday, The Christian Science Monitor)

With states feeling the pinch of Medicare and Medicaid spending--and rebelling in some cases--the federal government is using stimulus act spending to provide $4.3 billion to states to for prescription drug costs. Governors from New York and California say more is needed. (Health Leaders Media, Reuters)

In case you missed it ...
Drug companies contributed financial support to more than half the nation's internal medicine residency programs, even though three-quarters of residency directors said such aid is "not desirable." At issue are the pocket guides, meals, office supplies and drug samples given to doctors just as they gain the power of the pen. (New York Times, JAMA)
Monday, February 22, 2010

QD: News Every Day--president releases new health reform proposal

ACP Internist's daily digest of news and events continues with a look at the latest on health care reform.

President Obama released his new proposal for health care reform today, in advance of a bipartisan health summit scheduled for this Thursday. The plan is modeled on the bill passed by the Senate in December but would cost $79 billion more, although less than the $1.05-trillion House bill, the New York Times reported. Republicans called the proposal "government takeover of health care," while the White House billed it as an "opening bid" for Thursday's meeting, the Washington Post said. The White House has posted a summary of the proposal online. (New York Times, Washington Post,

Medical News of the Obvious

Continuing last week's "All I Need to Know about Medicine, I Learned from TV" theme, we have a new study about television portrayals of seizures, reported by HealthDay. Turns out that, actually, television is not the best way to learn first aid. According to these researchers, sometimes fake doctors fail to provide appropriate medical care! So much for that plan to take the boards based on watching four years of "House," "Grey's Anatomy," "Private Practice" and "ER."

In another follow-up from last week, more news that you probably learned in sex ed class. Men don't like condoms that don't fit, HealthDay tells us. In addition to being uncomfortable and more likely to be removed, ill-fitting protection also increases the risk of malfunction. The good news for TV watchers is that study authors suggested readying the problem with "public health efforts designed to promote the improved fit of condoms." So can we expect a plot line about condom fitting in an upcoming episode of "Grey's"?
Friday, February 19, 2010

Confidence And Doubt: The Language Of Clinician Versus Researcher

This post by Nicholas Genes, MD, PhD, originally appeared at Better Health.

There's an adage I often think about: "A physician's job requires the expression of confidence. The researcher's role is to express doubt."

This was never more apparent than when I transitioned from the research environment into the clerkships of medical school. The language of decision-making had abruptly changed. In the lab, a year's worth of experiments is summarized with "seems" and "suggests," and every assertion is carefully calibrated to acknowledge uncertainty and a high standard for proof.

As a student on clerkships, I couldn't quite wrap my head around the residents' ambitious plans for patients:

"Check CBC, electrolytes, chest X-ray, EKG, oh, and, he needs a head CT."

This use of "need" too often seemed careless to me, as if any patient could need a test that was almost certainly going to be normal, that in most parts of the world would never even be considered.

But in the residents' perspective, I came to understand the head CT was just an expected component of the patient's management. It had nothing to do with likelihood ratios or pertinent life-threatening conditions that must be explored. It was simply part of the story for certain patient scenarios, and couldn't be omitted without raising a lot of questions.

"We should also check a TSH level."

Few patients ever needed a TSH level, as far as I recall—this wasn't something that would hold up discharge, for instance. But checking thyroid function was often something that should also be done. Again, not because the residents had a firm grasp of the prevalence of thyroid disease in certain populations, but rather, because it demonstrated a thorough workup and, while not an essential or expected part of management, was nice for the attendings to see.

Over time, I gradually adjusted to this very nosocomial interpretation of "need" and "should." Now that I'm an attending, and the students' and residents' plans are a lot more hypothetical (until they get my approval), I'm hearing a little more "want" and "think" and "maybe." For me, it's a welcome return—a language more in line with my background, and one that acknowledges the uncertainties of medicine.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--health reform smacks into health insurance

ACP Internist continues its look at health care reform efforts in the U.S. Reconciliation might be back. Not between Democrats and Republicans, but the procedural move that could attach health care reform to a budget bill that requires a simple majority in the Senate instead of a filibuster-proof supermajority. That's the stick the White House is wielding if the health care summit on Feb. 25 doesn't produce results. President Barack Obama will release details Monday about his plan for comprehensive reform. (AP, New York Times, Los Angeles Times)

It's a perfect storm for health insurance. The economy has driven record numbers of people to Medicaid. 15 million more people could be added, but states are cutting programs and reducing payments to doctors. Medicare Advantage premiums are rising and private insurance rates are climbing, too. President Obama is using the private insurance rates as a talking point to push his agenda. (Washington Post, New York Times, Los Angeles Times, Reuters)
Thursday, February 18, 2010

QD: News Every Day--Politics and health care in America and England

Stalled legislation in the House and Senate moved ever-so-slightly, as President Barack Obama plans to use the bills as the basis for next week's health care summit, Health and Human Services Secretary Kathleen Sebelius announced. She also pointed to rising insurance premiums as evidence of the need for reform. (CNN, AP/Washington Post)

In England, Conservative and Labour parliamentarians are fighting about hospital readmission rates. Conservatives do not want to reimburse hospitals for the initial visit if the patient is readmitted as an emergency for a related problem. It's not a punishment, but is meant "to remove the incentive for them to discharge patients without proper support."

In England, about 500,000 patients are readmitted within a month of discharge, emergency readmissions increased by 52% between 1998 and 2007, and hospital beds have been cut by 12% in the last five years. (The Telegraph)

Electronic health records
SK&A, a health care marketing firm, announced electronic medical record adoption increased by 3.2%, to 36.1%, over a similar study last year. The report broke down the data by size, specialty, volume and other demographics. It also assessed software functions in relation to “meaningful use” criteria:
--Physicians primarily use electronic medical records for notes (28.3%) instead of labs results or e-prescribing;
--EHR adoption increases with the number of physicians, exam rooms and daily patient volume;
--EHR adoption is more prevalent in hospital-owned (44.1%) or health system-owned (50.2%) sites. Other practice ownership models hovered at about one in three for EHR adoption; and
--Dialysis, critical care medicine and radiology practices are the highest adopters, and allergy/immunology, general surgery and general practice are the lowest adopters.
Wednesday, February 17, 2010

Primary Care Physicians Are All One Breath Away From Dropping Medicare

This post by Rob Lamberts, ACP member, originally appeared at Better Health.

I am going to state something that is completely obvious to most primary care physicians: I do not accept Medicare and Medicaid patients because it is good business, I accept them despite the fact that it is bad business.

In truth, I could make that statement about insurance as a whole; my life would be easier and my income would be less precarious if I did not accept any insurance. If I did, I would charge a standard amount per visit based on time spent and require payment at the time of that visit. This is totally obvious to me, and I suspect to most primary care physicians. A huge part of our overhead comes from the fact that we are dealing with insurance. A huge part of our headache and hassle comes from the fact that we are dealing with insurance.

If I chose to post my charges up front and expected payment at the time of the visit, the impact to the business would be huge. As it stands, the percentage of my collections that goes to overhead is between 50% and 60% (depending on the month). A huge amount of that overhead is due to the need to hire a large billing staff to deal with the complexity of coding, billing and documenting. If I dropped insurance and charged a fixed amount, I could:

--cut my billing staff nearly to zero (someone would still have to do bookkeeping),
--increase my payment per visit, which would allow me to see fewer patients per day,
--document for the sake of patient care, and not for the sake of getting paid, and
--add extra services like e-mail access and house calls without worrying about how I would get paid.

In short, I could make my life better, my hassle less, and improve the quality of the care I offer.

So why just single out Medicare and Medicaid (M/M)? Dropping insurance would force all of my M/M patients to find another doctor, while my patients with insurance could still choose to see me. There are several reasons why this is possible for insured patients:

--Insured patients generally have the option of filing for their own insurance (there are some that still don't allow this, but that number is dwindling with the decrease of HMO's); and
--Insured patients could choose to just pay me cash if they choose.

Can't Medicare/Medicaid patients do this? No, for several reasons:

--If a doctor does not accept M/M, the government will not pay anything for the visit regardless of who files;
--If the doctor does accept M/M, they are required to accept that payment and cannot charge anything outside of that (aside from the 20% not covered). So if I charge a M/M $50 cash for a visit and am a signed up to accept M/M, I am committing fraud; and
--If I drop M/M, I cannot sign up for it again for three years, so the impact of that move is too large to consider at this time.

So why in the world do I accept M/M still? Why would I continue to make my life so difficult? Two words: duty and calling. I view my seeing M/M patients as a social responsibility (especially Medicare). These people need to be seen and they deserve good care, and despite the hassle and drain on income they cause, I make a reasonable income. So far.

Plus, I just like to take care of the elderly and the poor. My personal reasons for going into medicine included both a desire to have a good job and the calling to care for people in need. If I dropped M/M I would reject the calling for personal gain, which is something I can't do in good conscience at this time.

The fact that the only thing keeping me accepting M/M is my conscience (and tolerance of pain) gives a really clear explanation as to why M/M are failing in the realm of primary care. The government is not paying enough to make a good business case to accept M/M; instead it is relying on the consciences of primary care physicians like me who are willing to put up with the huge hassle of the system. I am personally willing to continue on this course as long as (it doesn't get too much worse) but I have complete sympathy for primary care physicians (PCP) who drop insurance and no longer see M/M patients.

One of the biggest costs to our system is the high proportion of specialists to PCP's. PCP's keep down cost, as their success is measured by keeping people healthy, away from specialists, and out of the hospital. The system is just holding on with the PCP's we have; decreasing that number would be devastating and perhaps fatal to the system. It's a very bad sign when the best business model for PCP's is to do something that, if done by all PCP's, would wreck the system. Yet even physicians like myself, who have a strong sense of duty and social responsibility, wonder how long we can afford to take M/M.

I am sure some are thinking: Poor Doctors! They have to earn less money! They have to actually have a conscience! What a horrible thing! To that I answer with the fact that I have chosen to earn less money, increase my hassle and live by my conscience. At this time, most PCP's accepting M/M are doing the same. But setting up a system that requires the choice between conscience and sanity, between doing the right thing and self-care, is foolish. Pushing down M/M payments for PCP's will make a bad situation worse.

That's bad politics, bad medicine, and bad business.

Consider yourself warned, Washington.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--How the primary care shortage plays out

ACP Internist looks at how states are using grants to fix their primary care shortages.

Michigan launched grants for primary care doctors to repay medical school loans and is looking to tap into federal incentives to fill its needs in rural and urban shortage areas. Alaska also needs primary care doctors, so the state senate is pushing through recruiting incentives of its own. (They should show re-runs of Northern Exposure.) Rural Indiana doesn't have a quirky '90s hit television program to its credit, but it has nurse practitioners who are finding their niche on physicians-led teams--relieving the backlog and providing patient education. (Detroit Free Press, KTUU-TV, Journal & Courier)

There's especially good news about federal spending for health care. The $1.85 billion invested to date in health centers from federal stimulus spending translated into $3.2 billion in new economic activity in these communities. A report from The George Washington University School of Public Health and Health services adds that more than 1,100 health centers have received stimulus funds that will let them serve 21 million people next year, including 3 million more new patients. The centers tend to be located in areas with higher rates of unemployment and recent job losses.

California faces a big hurdle in primary care. There's only 700 geriatricians, a problem found everywhere else but particularly acute in Oakland. Stakeholders in the system discuss whether California could switch to a global payment system and accountable care organizations to try to make health care work. Something has to be done. The state's cash-strapped rural hospitals report cutting hours and services. (San Mateo County Times, California Healthline, California Farm Bureau Federation)
Tuesday, February 16, 2010

QD: News Every Day--states buck mandatory insurance

ACP Internist continues its look at the states' rebellion against a federal insurance mandate. Virginia may be the first to enact legislation that exempts its residents from a mandate that may never pass, and through a measure that might be unconstitutional. (New York Times, New England Journal of Medicine)

Evidence-based medicine
High-tech scanners are driving up the costs of preventive medicine. You knew that already, but just how much is the subject of the feature "Rise of the Machines." Meanwhile, bloggers cast their fingers at how pharma marketing has trumped evidence-based medicine. (The Fiscal Times,

In case you missed it ...
A survey of doctors shows that 60% struggle with their own weight. But, nearly 70% work out regularly. Physicians should practice what they preach about healthy lifestyles, says David Balis, ACP Member. He's a triathlete, by the way, so he's not only walking the talk, he's running, swimming and cycling it. (Dallas Morning News)
Monday, February 15, 2010

Your Doctor Will Now Be Fined For Putting Time With You Above Time With Your Chart

This post by Westby Fisher, MD, originally appeared at Better Health.

It's an age-old problem, made more complicated by our new era of electronic medical records: optimizing collections in a time of unprecedented price pressures on our health care complex. With the economic downturn and declining government payments for services, everyone in health care is feeling the pinch.

It is no secret that work not billed will ultimately be work not paid. Hospitals and practice managers, adept at business principles, know this. Deep down inside, doctors know this, too. Historically, doctors dictated when they billed their patients, even if it meant waiting over a week to do so. If a doctor was to take a vacation, some of those billings could wait until his return.

Not so any longer.

As doctors surrender their autonomy to hospital systems with electronic medical records (EMR), more and more pressure is placed on them to complete electronic transactions in a timely fashion. Bills submitted to insurers simply must have all of the necessary data up front when submitted electronically, lest they have a high coefficient of elasticity and bounce back for revision before being paid. The EMR is incredibly savvy at tracking how many patient encounters are left open, for how long, and by whom. Daily reports are generated and performance tracked by administrators. Some doctors blend into this computer-driven workflow naturally and are timely at completing records. Others are less so, accumulating open encounters for a period of time before sitting down to complete their documentation at a later date.

But delays in closing records have plenty of implications for patient care. For one, other providers can't see what the managing doctor's thought processes were during the patient's visit since their note does not appear "publicly" until the encounter is "closed" electronically. Tests that return before the note was completed might also be difficult to interpret based on the discussions held with the patient. Finally, there is a limit of how long Medicare or other insurers will permit claims to be submitted to assure payment for services rendered. In short, the clinical and financial log jam is significant when such delays to electronic documentation occur.

Physician and administrative leadership must assure timely documentation of patient visits and test results. To do so, a number of methods are tried, the most common being gentle reminders in person or by e-mail: a "carrot" of sorts. But when these fail, a more stern warning might be issued and if not completed, a stick can be levied not previously known to doctors: fines that must be paid on a per-open chart basis. Suddenly, documentation on a computer takes on new importance that supersedes future patient care until charts are completed. Invariably, this gets peoples' attention. In effect, the stick works.

Now if a reasonable time frame is allowed before the stick descends, even the most reticent of doctors can live with this approach. They understand the need for timely documentation. But how long should the grace period for chart completions or verifying test results be? One, three, five, seven, 10 or 14 days? Too long and finances and patient care lags. Too short, then doctors who do not reside at a computer terminal 24/7/365 will be unduly penalized for doing what they should be doing: talking to and examining patients, placing hands in and on patients, traveling between care facilities, rounding on wards or teaching students and the like. Further, if penalties are imposed after periods that are too short, the implicit (but never stated) expectation is that notes will be completed on-line after hours when the doctor is home or even on vacation.

Increasingly with financial and health care cycles shortening, it is clear that with improved "efficiencies" in health care delivery and billing practices inherent to EMR systems, increased pressure is being placed on doctors to stay connected to the EMR system--even with fines--that has little respect for physicians' personal lives or geographic location.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--health care reform, one state at a time

ACP Internist continues its look at health care reform at the state level. Idaho, Colorado and Utah are just a few of the states that are enacting their own health care reform efforts. But moving forward isn't easy at this level. (ACP Internist, St. Louis Tribune, Washington Post)

Primary care shortage
More medical schools are opening, but they may or may not solve the primary care crisis in rural areas. Lawrence G. Smith, FACP, is the dean of one proposed school. (New York Times)

H1N1 Influenza
Centers for Disease Control and Prevention estimates put H1N1's tally at 57 million Americans sickened since the outbreak began last April, 257,000 hospitalized and nearly 12,000 killed. A modest increase in infections since the previous report suggests the pandemic is waning. (Los Angeles Times)

Medical News of the Obvious

In honor of Valentine's Day, we've got some obvious news about dressing up and getting it on.

Confirming a fact that's well-known to any woman who has ever worn high heels, researchers found that walking heel-first requires less energy than tip-toeing. "In addition," reports HealthDay, "a heel-first foot posture 'may be advantageous during fighting by increasing stability and applying more torque to the ground to twist, push and shove. And it increases agility in rapid turning maneuvers during aggressive encounters.'" In other words, you're better off throwing your stiletto than trying to do karate while wearing it.

Walking in pretty shoes can also be harder when you're pregnant, or at least that's what I learned from "The OC." A study, reported by HealthDay, surveyed female college students about their thoughts on teen pregnancy after they watched either an episode of the popular TV show or a "news-type segment developed for high school students by the National Campaign to Prevent Teen Pregnancy" and found that "The OC" was a more convincing argument for birth control--a result that would be painfully obvious for anyone who's ever had to sit through the snorefest that is a high school sex ed class.
Friday, February 12, 2010

QD: News Every Day--D.C. digs out and lines up

ACP Internist continues its look at health care reform as opposing sides line up for an event still two weeks away. Both Democrats and Republicans are skeptical. (AP, Politico)

The states want reform now, so they are doing it for themselves. Colorado introduced 10 bills in reaction to the state's falling grades for children's health care. Measures range from aggressive Medicaid fraud auditing to standardized insurance billing codes and uniform insurance forms. (Denver Daily News)

H1N1 Influenza
The World Health Organization will decide later this month whether the H1N1 influenza pandemic has peaked. It remains the dominant flu strain and could become part of next year's vaccinations. (Reuters)

Organizations continue to lift restrictions prompted by H1N1. The latest includes pro basketballers the Cleveland Cavaliers, who have restored water fountains to their arena. (Or maybe they're just meeting their building codes.) But British Columbians aren't being so, well, cavalier about their sporting event (that is, the Olympics). They're offering H1N1 shots to all athletes and spectators. (FanHouse, PBS)
Thursday, February 11, 2010

QD: News Every Day--Health policies slow to impact best clinical practices

ACP Internist continues its look at subjects important to internal medicine. Today, we follow the money.

Evidence-based medicine
The U.S. could save one-third of the $15 billion spent on stents annually if all doctors followed COURAGE trial conclusions and used generic drugs first, and stents only if pain persists. William Boden, FACP, headed that trial, and now says that reimbursement drives clinical practice. Dartmouth's Elliott Fisher, MD, says this "perverse incentive" doesn't improve health care. (Wall Street Journal, CNN)

Physician reimbursement reform
Following the Food and Drug Administration's record-breaking budget allocation, seven former agency commissioners and interest groups are still saying it's not enough to make up for years of underfunding. Even regulated industries want more funding to boost the public perception of product safety. (ACP Internist, Los Angeles Times)
Wednesday, February 10, 2010

Snowmaggedon And Physician Responsibility

This post by Steve Simmons, MD, originally appeared at Better Health.

I practice medicine in the suburbs west of Washington, D.C., and everywhere I look I see 30 or more inches of snow. I keep reminding myself of where I am--not unlike a man pinching himself to ascertain wakefulness--because the view my window affords me is tailor made for the usual snow typical to Buffalo, N.Y. Two days after the snow stopped falling, schools are cancelled indefinitely, most side streets have yet to see a plow, and tens of thousands are without electricity, including my partner's family huddled together like in a dark basement enjoying the extra two or three degrees of warmth to be found there.

Snowmageddon by by angela n. via FlickrIt is hard, but not impossible, to practice medicine when the pace of modern society grinds to a halt. Yet at least we, here, enjoy the benefits of living in a country with a well developed infrastructure prepared to rebound instead of recoiling from nature. To compare our "snowmageddon" (a term used on the news here) and the earthquake in Haiti would be both inappropriate and naive; yet, our daily lives have distinctly altered and in that an understanding of the fragility of society and the responsibility of a physician is possible. Still, there are many differences. We ask when our power will be returned, not if; snow will melt, but buildings don't un-crumble; and while my neighbors shiver together in their homes, many Haitians seek their loved ones with a shovel.

I know a few physicians who have been to Haiti and spoke with another today whose trip is planned for next week. I admire them all. Another doctor recently returned from Haiti was on the local news last night, shoveling the mountain of snow that had been waiting for him on his return home, a smile was on his face. The story they tell of Haiti isn't funny; it is one of an absent medical infrastructure and chaos, and still they go. One doctor described the coordination of Haitian medical relief as being akin to a group of five-year-olds playing soccer. Another story tells of doctors fleeing an angry crowd surrounding an unequipped hospital, their guards brandishing M16 rifles.

Nothing we see here could ever compare to these stories. However, people have died of carbon monoxide poisoning, accidents and the inevitable snow-shoveling heart attacks. My concern must be with my family and patients here and now. What do they need? What role should I play to best serve them today? We have been unable to open our office, let alone get to it but my practice does not rely on seeing patients face-to-face to treat. We don't have to generate insurance paper-work to keep the lights on or meet our overhead. Our laptops are open and pharmacies are filling our prescriptions. In our practice we continue to care for our patients using the telephone and e-mail to apply basic triage to patients we have already met and know. Most phone call visits are limited to upper and lower back pains plus a medley of other sore muscles, ligaments, and then attitudes, as the forecast for Wednesday morning's weather included up to 20 more inches of snow for our area.

American doctors, fortunate enough to practice medicine in the 21st century, should not become complacent or too dependent on the daily flow of patients through our offices. We must be able to adapt to circumstance and react to emergency. Society will depend on us and I, for one, am optimistic that our profession stands ready and will meet any challenges thrown our way as evidenced by recent events. The bravery of physicians volunteering in Haiti ennobles our entire profession and we can all feel pride in their actions. The responsibility towards all of our patients will not lessen after unforeseen events. Rather, it will increase and the chance to respond magnificently awaits us all as we support our patients in the seemingly mundane affairs of day-to-day living.

Until next week I remain yours in primary care,

Steve Simmons, MD

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--reform for patients and relief for providers

ACP Internist continues to daily news round-up with a look at health care reform.

Health care reform
President Barack Obama signaled his willingness to compromise in order to achieve at least some aspects of health care reform legislation. But he also took his shots as well, cautioning Republicans against "obstinacy." (AP, Politico)

Even if federal legislators find common ground, the states are still rebelling. The latest salvo, just as one example of its kind, finds Idaho's lawmakers debating a law that would pre-empt business and individual insurance mandates and sue the federal government that tries to enact them. (KIFI TV 8)

Physician reimbursement reform
Darn nail by °Florian via FlickrCongress attached language to stop a 21% cut in Medicare reimbursement to its jobs legislation. But Congress is trying to patch the same old tire, (free registration required) says ACP President Joseph W. Stubbs, FACP. Congress is attempting to earmarks $82 billion to overhaul Medicare's sustainable growth-rate. But its $200 billion debt will rise until there is a permanent fix, he said. (NPR, Modern Physician)

It's Not Our Fault

This post by Rob Lamberts, ACP member, originally appeared in Musings of a Distractible Mind in September 2008.

Dear Patients:

I know you get frustrated with our office. We make you come in for visits when you think we should handle things over the phone. We seem more focused on your chart sometimes than on you. Sometimes you may even wonder if money has become more important than patients.

To this, I say: I'm sorry. It's not our fault.

We are part of an insane system that requires us to do things in a way that makes life harder for us both. We would love to practice medicine differently, but we simply can't. Here are some examples:

1. Making you come in all the time

I would love to handle your simple problems on the phone or via e-mail. The problem is that if I do this, I am giving free care for which I am liable. People are being sued for nearly everything. If we give you a medicine without seeing you, we are actually more at risk than if you come in. Plus, the only way we can get paid is to bring you in. Insurance won't pay me for handling your problem any other way. Even if we both agreed, we couldn't have you pay for a phone call or e-mail, because we would be breaking our contract with our insurance company.

2. Not ever giving discounts

If I choose to give you a break and not charge you for a visit, I am being nice. Right? Well, according to our government, I am actually committing fraud. That's right, fraud. You see, I can't offer anyone a discount that I don't offer to Medicare patients; and not charging you would mean I have to not charge my Medicare patients. Ridiculous, isn't it?

3. Getting lost in notes

Why do we spend so much time taking notes and not talking to you? Is it so that we can do better medicine? No, we actually think that all this charting is stupid too. The problem is that we don't get paid to see you, we get paid to chart about you. We are paid based on a complex set of rules of documentation and if we are able to document more, we are paid more. If we cut corners so we can spend time with you, we are again viewed as committing fraud.

4. Obsessing about money

When you get your bill from us, you may wonder what all those charges are. And why are we forcing everyone to pay up front and sending people to collections? The problem is, while health care insurance premiums have gone up and inflation has raised everyone's cost of living, our reimbursement has dropped. We get paid less and less for taking care of you, so we have to become much stricter in how we run our business. The practice of medicine has turned into the business of medicine. We didn't do that, nor do we like it. But we have to stay in business, so we do what we must.

5. Not seeing you in the hospital

It seems like the time you most need your primary care doctor is when you are in the hospital, yet we don't see adult patients in the hospital. Believe me, we hate that as much as you do. It is very hard to give your care over to others who see you as "another patient." They don't know your history like we do and are often too busy to answer your questions. We try to communicate with them, but it is just a hard thing to do.

The problem is that we can't afford to see patients in the hospital. The amount of time it takes for the money we get is just not worth it. It came down to what was the least-bad thing to do: stop seeing patients in the hospital, see our families less or see our salaries drop. As primary care providers, we are not paid enough to let our salaries drop, so we chose our families. It was one of the hardest choices we ever made.

6. Acting paranoid

Why does the nurse always tell you to go to the ER when there is even a small chance there may be a problem? Why are you treated like a criminal if you ask for pain medications? The answer? Lawyers. Lawsuits are so rampant in our culture and so it makes us practice "defensive medicine." This means that we can't do what makes sense, we must do what minimizes risk.

And if we are ever thought to be giving pain medications too liberally? We can lose our licenses and even go to jail. It's a dangerous business we are in, but we don't want to do anything to make it more dangerous.

I am truly sorry for the state of things as they are. Perhaps better days are ahead of us. Some politicians are actually talking about paying primary care doctors more. Some people are suggesting that they stop paying just based on charting, but actually reward better work. And some people are even talking about limiting malpractice rewards.

These all sound promising, but remember who it is that is making the decision: It isn't the doctor or the patient, the two people who the whole thing is about; it is the politicians, bureaucrats, and insurance companies controlling this stuff. Unfortunately, with them in charge it is probably not wise to hold our breath.

Stay healthy, and have a great day!


Dr. Rob

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.
Tuesday, February 9, 2010

Drink beer, not soda

Every so often we like to condense the latest in nutritional research down to some news you can use. The info this week seems to be all about drinks.

Unfortunately, this data comes a little too late for Super-Bowl party planning, but keep it in mind for next time: beer is good, soda is bad. OK, so, it's not really quite that simple.

New research has found that some beers--especially hoppy ones--have a lot of silicon in them, which can be good for bone density. Annoyingly, none of the coverage of this study tells you which specific beers to drink, but perhaps that's thanks to the study author, who was quoted by Reuters. "'I would first consider flavor and whether you like it or not,'" he told science and technology magazine Discover. "'Choose the beer you enjoy, for goodness sake.'" Now there's a man with a pleasing sense of humility about his own research.

The soda researchers, on the other hand, left it to their colleagues to dismiss the significance of their results, in a HealthDay article. The observational trial found that heavy soda drinkers had a higher risk of pancreatic cancer, but it didn't control for other unhealthy behaviors the people may have been engaging in, like smoking. Soda companies, not surprisingly, disputed the association.

QD: News Every Day--Approaching a summit from opposite sides of the mountain

Health care reform
The White House summit between opposing sides of health care reform is planned for Feb. 25, with broadcast coverage on C-SPAN. The summit has drawn criticism from those opposing last year's effort, but that didn't stop opposition leadership from sending ahead some pointed questions and asking for a response. [Hint: They want the answer to be, "Start over."] (USA Today, Washington Post)

Haitian relief efforts
Telemedicine has arrived to Haiti. While waiting for hi-tech hookups, ham radio operators have aided in communications. (New York Times)

Patient-centered medical home
Five counties in north Texas have adopted a widespread medical home concept. It's led by an insurance company in conjunction with two large physician practices. (Dallas Morning News)

Vitamins in a Nutshell

This post by Davis Liu, MD, originally appeared at Better Health.

Some patients love their vitamins, spending hundreds to thousands of dollars annually. At times, they will even forgo proven medical therapy. As more Americans go without health insurance coverage while others face higher office visits and copays, increasing numbers of patients are seeking alternative, natural therapies instead of medical care. Are vitamins really the scientific breakthrough and secret that doctors refuse to recommend, or are they simply marketing hype? As any medical school student will tell you, the correct answer to any question is: it depends.

Vitamins! by bradley j via FlickrFor certain groups, pregnant women, patients with macular degeneration and vegetarians, vitamins and minerals may be recommended as research finds them helpful. Prenatal vitamins have more folic acid, which has been found to decrease the risk of neural tube defects in the fetus. Vegetarians may need to supplement their diet with vitamin B12, iron, and vitamin D, which are absent in their food choices.

Patients with a history of gastric bypass should be on a multivitamin that contains iron and vitamin B12. The surgery, which is used to cause weight loss in morbidly obese patients, can bypass part of the digestive tract responsible for absorbing these nutrients.

Women of all ages should take calcium and vitamin D to improve bone density to decrease their future risk of osteoporosis. This means at least 1,000 mg of calcium daily and vitamin D 800 to 1,000 international units (IU) per day. Women over 50 should be taking 1,500 mg of calcium/day. A common misconception is that a multivitamin has enough calcium. It doesn't! A typical multivitamin has about 45 mg of calcium (a glass of milk is about 300 mg).

Aside from these individuals, the result of us with a balanced diet should get the right amount of vitamins and minerals. You don't need the large mega-dose vitamin packs found at your local warehouse store or nutritional shop. Not only are they expensive, but also unproven.

If you still feel like you can't get through life without taking vitamins, then at least be aware of the following:

Limit the amount of fat soluable vitamins that you ingest, specifically vitamins A, D, E and K. Unlike water soluable vitamins, of which excess amounts are excreted by the kidneys, fat soluable vitamins can build up levels in the body.

For vitamin A, toxic levels begin after ingesting more than 50,000 IU daily. Upper limit of tolerable intake (what is considered the upper limit of normal but still safe) is 10,000 IU. Recommended daily allowance is 3,000 IU.

For vitamin D, the upper limit is 2,000 IU. The current daily allowance is 600 IU. A new recommendation is expected in May 2010 by the Food and Nutrition Board. Vitamin D is obtained by the skin via sunlight exposure. With people indoors more often than generations ago and possibly the increased use of sunscreen, doctors are seeing more cases of vitamin D deficiency. Your doctor may prescribe a weekly dosage of 50,000 IU weekly for three months to replace. Low levels of vitamin D can cause muscle pains, so if a constant problem, ask your doctor to check your levels. (Cod liver oil, incidentally, is rich in vitamin D and is probably why growing up in Canada I had a lot of it during the winter. Ick.)

For vitamin E, the recommended dosage is 22.4 IU with the upper limit of tolerable intake no more than 1,500 IU. Some research suggested that there was increased mortality for those individuals taking more than 400 IU per day. Because of its antioxidant properties, researchers thought taking more was better. It wasn't.

For vitamin K, found in green leafy vegetables, it is the only fat soluable vitamin where there is no defined upper limit for toxicity. Overdose of vitamin K is rare.

Am I against vitamins? Of course not. For some patients, in fact, they are recommended. What I am against is, however, having individuals spend their hard-earned money for therapies that aren't proven. Note that the FDA, under current legislation since 1994, has no oversight over nutritional supplements.

This is why all vitamin package inserts have the following statement:
* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.

Want to live well? A better insurance policy than vitamins is to not smoke, perform regular physical activity, take in five servings of fruits and vegetables, and possibly drinking alcohol in moderation (as a doctor I can't recommend that, but if you drink already, it might be ok). Researchers found individuals who did all four behaviors added 14 years to their lives. Why don't more of us these activities? They all take some effort. Swallowing vitamins are quicker and easier.

If I still haven't convinced you not to take unnecessary vitamins, then at least check with your doctor before stopping your medical therapies or adding supplements that can interfere with your treatment.

Finally, please avoid colon or total body cleanses. Sounds natural and healthy, but again aren't required. A product found at a large nutritional chain's special "anti-oxidant" formulation basically consists of fruits, vegetables and fiber. You can do that yourself for a lot less, and it probably tastes better too.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Monday, February 8, 2010

You can date your patients after all.

What with all those pesky ethics rules, it's not often that the line between romance and medicine gets blurred. But a new article (in the business section of AMedNews, of all places) brings the topics closer together than usual.

The story even begins like a romance novel. "The young woman wondered: Could Dr. Emmet be the right physician to perform her first pelvic exam?" Thankfully, before the situation deteriorated into any heaving bosoms, the article explains the woman and the doctor were participating in a physician-patient speed date. That's right, speed dating, an activity formerly confined to dark singles bars, could be headed to a hospital cafeteria near you.

At this Texan event, a group of physicians in need of patients and patients in need of physicians met and chatted to see if they were compatible. If they hit off, the pairs made appointments rather than second dates. But it's amusing to consider what kinds of icebreaker questions would have worked in both types of speed dating: "Are you looking to have children soon?" is probably OK, but "When was your last full-body exam?" might take some daters aback.

QD: News Every Day--Obama calls for a health reform summit

Health care reform
In a bid of showmanship, President Barack Obama invited Republicans to the White House for a televised half-day summit to lay out ideas for health care reform. During the president's State of the Union address, he asked if anyone had better ideas to bring to the table, and a chippy House Minority Leader, John Boehner, raised his hand. Here's his chance to speak. (Wall Street Journal, TIME)

H1N1 influenza
The H1N1 epidemic has "one foot in the grave," William Schaffner, MACP, told TIME magazine. Anne Schuchat, FACP, updated reporters about the issue last week. (transcript and audio)

With that good news, the Roman Catholic Archdiocese of Boston plans to restart offering the Communion cup and sharing the Sign of Peace, which were stopped because of its spread. Meanwhile, professional hockey's New York Islanders will host free flu shots to all fans at tomorrow's game. (Leave your own punch line in the comments field.) (WHDH-TV,

In case you missed it ...
A Dallas-Fort Worth area hospital used the speed-dating model to match patients to primary care physicians. In case you're not familiar with the concept, speed dating involves quickly rotating people for chats of a few minutes at a time. At the end of the event, people decide who they'd like to see again. (American Medical News)

Medical News of the Obvious

Again this week, the mainstream reporters are doing our job for us. Newswise brings us reports of "an unmet need to study what might seem obvious: Gay kids will be pushed around." Researchers, published in the Journal of Adolescent Health, attempted to fill that need by surveying thousands of kids to learn that the very few who identified themselves as homosexual (less than 2%) or bisexual (0.5%) were also more likely to be bullied than the blend-in-with-the-crowd heteros.

In other news of those mysterious little miniature humans, it turns out that kids don't take themselves to the dentist. "About 86 percent of children whose parents had a dental visit during the preceding year had a dental exam, compared to about 63 percent of the children whose parents hadn't," HealthDay reports. What, that other 23% couldn't get it together to call a cab or hitchike to the dentist's office?
Friday, February 5, 2010

Airplane Medicine: What Happens When You Answer The Flight Attendant's Call For A Doctor

This post by Liam Yore, MD, originally appeared at Better Health.

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

But gee, I can hear you think, Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory? Well, yes. But, first of all, there is the performance anxiety thing. I'm used to working with a very small audience. In economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room--and I know they are very interested in what's going on.

Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

Click on the "More" link to read the full post.

So, on Olympic Air, somewhere over the mid-Atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back.

Great, I thought to myself, It's an aortic aneurysm. (See? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again ... there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking someone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that.

The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell. As I stood up, I saw an elderly man about 10 rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in.

Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain. I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane. So I sat up in first class with him to keep an eye on him (The wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be--probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better. And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

QD: News Every Day--The government's rising stake in health care costs

The federal government may be stalled on health care reform legislation, but the executive branch has been expanding its stake in paying for care.

Yesterday, QD reported that federal and state governments will pay for more than half of the health care purchased in the U.S. by 2012, and likely even sooner. Today, Medicare's actuaries announced that growth in national health expenditures (NHE) outpaced growth in the Gross Domestic Product (GDP) last year. The recession, H1N1 programs and federal subsidies for COBRA benefits all contributed to the largest one-year increase in history, from 16.2% of GDP in 2008 to 17.3% of GDP last year.

In 2010, NHE growth will decelerate to 3.9% while GDP is anticipated to rebound to 4% growth. But, and this is a big caveat, much of the projected slowdown in NHE growth is attributed to the 21.3% slashing of Medicare physician payment rates called for under current law’s Sustainable Growth Rate provisions.

We here at QD love a good chart to explain all this, and there's plenty to peruse.

Also released today is a report that, one year after expanding Children’s Health Insurance Programs, 2.6 million more children gained Medicaid or CHIP coverage. As a result of the extra federal spending, all but two states cover children in families earning at least 200% of the federal poverty level, ($48,100 for a family of four in 2009.)

Health care reform
Speaking to a friendly audience, President Barack Obama broadly outlined his goals for moving forward on health care reform. He called for a "methodical, open process" and a public airing of ideas from partisan legislators and non-partisan experts. Vice President Joe Biden backed up those statements, but U.S. House leaders dodged the topic following a meeting with the President. (New York Times, The Hill, Politico)

Invest in Primary Care to Bring Costs Under Control

I went to my physical therapist yesterday for knee treatment and we talked about the fact that Blue Cross is cutting their reimbursement to the point that the cost of providing care will not even be covered. All I could do was lament with him and listen. One insurer even told him (the owner of the business) to just "make the sessions shorter and don't give as much care." As if that is how it works: "You get little money, so just do a little".

Clearly the insurance intermediaries, who never actually see a patient or deliver any care, haven't got a clue how this whole health thing works. They are happy with mediocre doctors that cut time and care. Those doctors (and physical therapists) run mills, but the insurance companies are happy with them. Quality and quantity of time are not rewarded, and in fact are punished in the health care environment we have.

He asked me if primary care had any problems like that. (I felt like screaming "Aren't you reading my blog?") More the point, why doesn't the entire population know that access to a primary care physician will become as rare as swimming with dolphins? It will depend upon how much money you have to buy concierge/retainer medicine. Where you live will play a role. If your community has a large multispecialty clinic, like Kaiser or Sutter Palo Alto Medical Group, you may have access.

Doctors in training are flooding away from general internal medicine, pediatrics and family medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lerher report discussed the reasons. We've been talking, talking, talking about it for years but things have only gotten worse, not better.

The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation--primary care that is valued by the government, the payers, the population and even by the physicians.

We have it all backward. It is time to revamp the system from the bottom up. Frankly, I don't care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new " next generation" imaging scanner until we can rationalize how we pay for care.

We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers (you know who you are, Ed) said "You can't clear the swamp until you get the pigs out of the way."

We have a lot of pigs to move aside so more people can get to the water.

Toni Brayer, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.
Thursday, February 4, 2010

Reflexive Doubt: The Psychology Of Misguided Scientific Beliefs

This post by Amy Tuteur, MD, originally appeared at Better Health.

Those of us who study, practice and write about medicine cherish the hope that explaining the science behind medicine (or the lack of science behind "alternative" treatments) will promote a better understanding of medicine. Certainly, I would not bother to write about medical topics if I did not believe that promoting science-based medicine would lead to increased understanding of medical recommendations and decreased gullibility in regard to "alternative" remedies. Nonetheless, lack of scientific knowledge is not the only reason for the current popularity of "alternative health. Indeed, many advocates and purveyors of "alternative" health are impervious to the scientific evidence. What else might be going on?

Belief in "alternative" medicine is a complex social phenomenon. Like any complex social phenomenon, the explanation cannot be reduced to a simple answer. But I would argue that there is an important philosophical component, developed by and promoted by advocates of "alternative" health. That philosophical component is the rise of reflexive doubt. Simply put, among a significant segment of society, it has become a badge of honor to question authority.

As an obstetrician, I am most familiar with its expression among childbirth activists. They recognize that many people hold the common sense belief that modern obstetrical practice has made birth safer, and have worked ceaseless at undermining this common sense view.
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Craig Thompson, a professor of marketing, has examined this tactic in his paper What Happens to Health Risk Perceptions When Consumers Really Do Question Authority?:

... [U]sing the natural childbirth community as a context ... helps us understand how groups of people come to deeply believe in anti-establishment risk norms ... Natural childbirth activists believe that low-tech midwifery ... provides the best labor outcomes, except for in a small percentage of high risk cases. They also believe that the medical practices of childbirth pose a host of unnecessary and avoidable risks ...

...Childbirth reformers interpret ... innovations ... as unnecessary intrusions whose primary function was enabling physicians to display technical skill ...

... During the past 50 years, many obstetric interventions that were once deemed to enhance the safety of birth or to improve postpartum outcomes--shaving of the women's pubic region; mandatory intravenous drips ... enemas--have all been discarded as ineffective, unnecessary, and in some cases, potentially harmful. The natural childbirth community invokes this historical legacy to argue that many contemporary obstetric interventions are likely to meet a similar fate.

In other words, the apparent success of modern obstetrics is illusory. Innovations were unneeded and developed simply to enrich physicians. Moreover, obstetrics has been mistaken in the past so no one should trust it in the present. Therefore, questioning the claims of physicians, and reflexively doubting explanations is not merely necessary, but is the mark of and "educated" and "empowered" consumer of health care.

Such tactics may have originated with the "natural" childbirth movement, but they have arguably reached their apogee with the vaccine rejectionists. That's why millions of parents consider former Playboy playmate Jenny McCarthy a reliable source on vaccination. No one argues that she has any formal training in immunology or even that she understands the science behind vaccination. That's not necessary. She is admired by a community that has come to believe that reflexive doubt is a sign of sophistication and education.

As Hobson-West explains in Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK, vaccine rejectionists generally ignore the actual scientific data, focusing instead on whether parents agree with health professionals or refuse to trust them. Agreement with doctors is viewed as a negative and refusal to trust is viewed as a positive cultural attribute:

Clear dichotomies are constructed between blind faith and active resistance and uncritical following and critical thinking. Non-vaccinators or those who question aspects of vaccination policy are not described in terms of class, gender, location or politics, but are 'free thinkers' who have escaped from the disempowerment that is seen to characterise vaccination...

This characterization of vaccine rejectionists can be unpacked even further; not surprisingly, vaccine rejectionists are portrayed as laudatory and other parents are denigrated.

... instead of good and bad parent categories being a function of compliance or non-compliance with vaccination advice ... the good parent becomes one who spends the time to become informed and educated about vaccination...

... [vaccine rejectionists] construct trust in others as passive and the easy option. Rather than trust in experts, the alternative scenario is of a parent who becomes the expert themselves, through a difficult process of personal education and empowerment...

The ultimate goal is to become "empowered":

Finally, the moral imperative to become informed is part of a broader shift, evident in the new public health, for which some kind of empowerment, personal responsibility and participation are expressed in highly positive terms.

So vaccine rejectionism, like most forms of "alternative" health is about the believers and how they would like to see themselves, not about vaccines and not about children. In the socially constructed world of vaccine rejectionists, risks can never be quantified and are always "unknown". Parents are divided into those (inferior) people who are passive and blindly trust authority figures and (superior) rejectionists who are "educated" and "empowered" by taking "personal responsibility".

As Prof. Thompson notes in regard to believers in "natural" childbirth:

Importantly, their beliefs are far more than an abstract system of thoughts. The natural childbirth model shapes childbirth choices by being accepted as a structure of feeling ...

...The risks singled out by the natural birth model express cultural anxieties over the unintended and dehumanizing consequences of technology; the loss of individual independence through the workings of complex 'expert' systems; and a political project of supporting midwifery over the socially-accepted knowledge of the medical establishment.

Similarly, the purported "risks" of vaccination express cultural anxieties over unintended or dehumanizing consequences of technology, expert systems, and supporting self "education" over the accepted knowledge of the medical community.

In counseling patients about the claims and remedies of "alternative" health, we may need to do more than simply explain the underlying science (or lack thereof). We may need to address the philosophical beliefs about the value of reflexive doubt. Reflexive doubt is not laudatory in and of itself and it certainly is not a sign of being "educated." It is just a mindless rejection of authority, with potentially devastating consequences.

This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.