Friday, September 30, 2011

QD: News Every Day--Median hospitalist compensation up slightly

Hospitalists in adult medicine reported an increase in median compensation from $215,000 to $220,619 in 2010, while pediatric hospitalists median compensation rose from $160,038 in 2009 to $171,617 in 2010. Though hospitalists earned more in 2010, they also reported higher productivity. The annual median adult hospitalist physician work relative value unit (wRVU) rate was 4,166, a 1.4% increase over last year.

According to the Medical Group Management Association (MGMA) and Society of Hospital Medicine’s (SHM's) State of Hospital Medicine: 2011 Report Based on 2010 Data, compensation varied by how it was structured. Adult hospitalists with 50% base salary or less reported median compensation of $288,154, while adult hospitalists with 51-70% base salary reported median compensation of $249,250. Adult hospitalists who reported 71-90% base salary earned $213,542 in median compensation, and those with 91 to 99% base salary reported $221,270 in median compensation. Adult hospitalists with 100% base salary earned $205,003.

An analyst with MGMA said in a press release that hospitalist compensation is still evolving, which provides hospitalists room to negotiate for productivity and quality bonuses.

The report contains information on 4,633 hospitalists in 412 groups and 726 academic hospitalists in 68 academic hospital medicine practices, as well as group-level data on compensation methodology, group size and staffing mix, turnover and growth, staffing models and financial support.
Thursday, September 29, 2011

When instinct trumps expertise

A hard thing about being an ER doctor is that I know a little, sometimes very little, about a lot of things. When I am faced with a particular condition, I often need to call the specialist for that organ, who knows way, way more about it than I ever will, and they all think I'm an idiot because I don't know as much about their organ as they do. There's a huge asymmetry of knowledge, and it can create some tension and conflict.

I'm OK with it, because I can ignore their condescension and I am secure with what I do know, and its limits. But sometimes I get perplexing instructions from the specialists. The emergency medicine dogma can be overbroad and a little hidebound and what the specialists will do in the real world often radically diverges from what the emergency medicine textbooks say to do. It's often an interesting learning opportunity for me, especially when it's a condition I don't encounter that much. But I also have to work to maintain a flexible and open-minded attitude when I call a consultant and my side of the conversation consists of, "Really? I didn't know you did that for this?" You need to know and trust your colleagues in other specialties, and know when to call BS on them and push to do something else, which is really hard to do when you are talking to someone who is so much more of an expert than you are.

So I saw this guy recently, an urban hipster who was perhaps a bit too old to be riding his longboard on the hilly streets of our fair town. He didn't seem to be too good at it, judging by the collection of crusted abrasions and aging ecchymoses he was sporting. He had been falling a lot recently. We only get about a month of sun here, so I guess he was making the most of the summer weather practicing his new hobby. He had a variety of complaints from his recent falls, but it was a wound infection that had driven him to come in. A bit of road rash on his thigh was looking a bit cellulitic and I thought might benefit from some keflex.

I had to go through the motions of doing a more or less thorough exam, and he was pretty tender on his neck, I noticed. He said it had been hurting for about a week, since he had fallen backwards and hit his head on a car fender. He demonstrated how his neck was fully extended at the moment of impact, and the resolving goose egg on his scalp correlated. I wasn't terribly impressed by any of his orthopedic injuries, but I did order a few plain films, just to CYA, and I included a C-spine series as well, which is rare for me since if I really think someone might have a C-spine injury, CT scanning is the imaging modality of choice.

I actually got a little short of breath when I scanned through his images and this jumped out at me:
For those not accustomed to reading these, this is a fracture through the posterior part of the second cervical vertebra, also known as a hangman's fracture. You might infer from the name that this is an unstable, bad injury, and you would be right. And our hipster friend had been walking around (hell, skating around and falling) for a full week with this injury! His neuro exam, I confirmed, was rock-solid normal. We popped a C-collar on him and I called the neurosurgeon at the local spine center to arrange transfer.

I had the opportunity to hold forth, as the nurses and techs gathered around the monitor to see the image, explaining that the "hangman's fracture" is a bit of a misnomer. Generally it is sustained from axial loading (as opposed to traction), which makes a ton of difference. The real-world mechanism is planting your forehead into a car windshield, that is, not hanging from a rope, and the spinal cord is typically uninjured in mechanisms of this sort. It's unstable and needs to be fixed, but there are many worse c-spine fractures you could have. My audience was very appreciative and I basked in their attention.

I was quite surprised, however, when I eventually spoke to the neurosurgeon. "It's a stable fracture," he told me, "He's had it for a week and his cord is fine. Put him in a hard collar and send him home. I'll see him in clinic next Tuesday." It was one of those "What? Really?" moments I described above.

This surgeon, I should mention, was not some fly-by-night guy, nor was it the intern. He's a very respected professor at a university-affiliated trauma center. He's not someone I am predisposed to argue with. I see hangman's fractures about, oh, once a decade, and he operates on them all the time. He clearly thought it was quite routine to send him home. And he did have a point; it had been a week, after all. So with great discomfort, I acquiesced. For lay readers, it is important to understand that there are categories of stable spinal fractures that should go home, so it's not as crazy as it sounds. Not quite, anyway.

It seemed wrong, though, very wrong. I ran it by a couple of my partners and their eyes all got kind of big at the prospect, too. Without any clear plan, I decided to buy time and get the CT scan to better delineate the injury. After all, I reasoned, they will need it to plan the surgery when he goes to clinic next week. ("Next week? Am I really going to send a C2 fracture home for a week without even seeing the neurosurgeon? This is nuts! I just can't.") I chatted with the radiologist who read the CT, who described the hangman's fracture and blah blah blah, lots of technical details that meant nothing to me. I had radiology send the images electronically to the trauma center and sent a message to the surgeon that there was a scan available, in the hopes that might change his mind.

The surgeon called me back about ten minutes later, with a hint of anxiety in his voice. "Please tell me you didn't send that guy home, did you? This is a really bad, unstable injury. I need to operate on him today." To his credit, he had the grace to be embarrassed about his earlier advice and acknowledged that I was right to have stuck to my guns on this case.

I still don't claim to fully understand the intricacies of this injury or what about it changed the surgeon's mind. I'm not a neurosurgeon. I am very glad, though, that in this case I listened to my gut and that I didn't send him home. My malpractice carrier is, too. Knowing when to call BS, when to say "No" is one of the hardest things about my job, because it's pure instinct

This post by Liam Yore, MD, appeared at Get 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.

The cost of medical malpractice: part 2

A recent post was about medical malpractice and what it costs us in dollars. This time I want to take up a different cost: the human one. This post is not going to be easy.

As a physician, being sued for malpractice is a concern that enters my mind at least fleetingly on a daily basis. A recent article from the Aug. 18 issue of the New England Journal of Medicine is being widely quoted. Surveying claims data and a national databank of malpractice data, the study reported that by the age of 65 years, three quarters of doctors in "low-risk" specialties had faced a malpractice claim, and nearly all physicians in high-risk specialties had been exposed. They estimated that nearly half of us would be sued by the age of 45 years. Each year, an average of 7.4% of physicians had a malpractice claim filed against them. But, according to the study, a little more than three-quarters of all claims did not result in payments.

The threat of medical malpractice suits has an incalculable effect on the way doctors practice medicine in this country. I have already talked about the numerous unnecessary tests ordered by doctors practicing "defensive medicine." I have already talked about the way in which we are advised to obtain "informed" consent by scaring our patients half to death just by discussing every conceivable risk of even the most minor intervention. But I have not talked about the profound effect a malpractice suit has on the individual who is sued and the ripple effect it has on his patients. This post is about the effect it has had on me.

I am in what might be considered high-risk specialty. In other words, if I make a mistake somebody could conceivably be seriously injured or die as a direct result. Fortunately, such opportunities are a rather small part of my professional life in the same way that although driving to the grocery store is not considered a high-risk activity, there is always the possibility of going through a busy intersection and making a monumentally wrong maneuver and killing someone. In specialties that consist mainly of prescribing medication, medical misadventures are rarely immediately apparent, whereas in procedural specialties such as my own it becomes quite obvious if there is a mishap. So it is inevitable that someone like me will eventually be sued for malpractice. I don't think about auto accidents much, perhaps because I have thus far been lucky enough not to be in one. That was my attitude about malpractice.

A few years ago I was named in a suit involving a patient whose care I participated in and who had an "adverse outcome." She died. In spite of two years of diligent testing, and treatment by her physicians, we failed to recognize one of the less common but serious health consequences that her particular habits had led to. The patient's family blamed the primary care doctor, the consultants, and the first surgeon that was called to treat her. Perhaps all would have been forgiven if the second surgeon involved in the case, by which time the diagnosis was quite obvious in hindsight, had not told the family "If only they had sent the patient to see me sooner I could've done something." I don't think any of us was negligent or did not live up to the "standard of care," but that is what we were sued for.

I had never been sued before. I had attended a number of seminars over the years on how to avoid being sued when there is an adverse outcome. One of the most frequently repeated messages was the importance of maintaining a good relationship with the patient's family. Numerous examples were given of doctors who were sued only because they had made the patient or family angry, even though their care has been exemplary. There were numerous other anecdotes about patients who might justifiably have sued their physician but chose not to because they had a very good relationship. I pride myself on nurturing my relationships with my patients, communicating well, and maintaining what patients usually call a good "bedside manner." I even took what I now realize was a foolish pride in the fact that I had never been sued. I know now I had merely been lucky.

One day I was in my consulting room, in between patients, when my secretary buzzed in to say that there was a sheriff's deputy there to see me. I have occasionally been asked to provide legal documents for patients but on this occasion I couldn't imagine what was the purpose of the visit. I welcomed the gentleman into my office and his first words were "Doc, I'm really sorry because I have heard that you are really good doctor but I have to serve you with this." He handed me a thick envelope and with a few further apologies promptly took his leave. I opened it. Inside was an official court document informing me that in essence, I was being sued for malpractice in the matter of a particular patient and a list of allegations of various ways that I had failed to meet the standard of care for doctors in my specialty.

Although the implications are not nearly as serious, the initial sequence of emotions one goes through on receiving such news is not unlike people's reaction on learning that they have a diagnosis of cancer. I couldn't believe it. I was shocked. Then I was angry that I was unjustly "accused." But after that the sequence diverged. I didn't bargain. I set to thinking about what I might possibly have done wrong or could have done differently in that patient's care. I engaged in self-recrimination. I was angry at myself for having allowed this to happen; I must have done something wrong. That was the topics that was preoccupy me for the next few days and even weeks. Like many doctors, I am perfectionist and compulsive. After all, wasn't I was one of the select few talented enough to be granted the honor of great responsibility? Didn't I always get A's? I expect my work to be perfect. It is a great blow to think that one might have injured someone because of having made a mistake.

Of course my first response was to notify the risk management office at my insurance company. The attorney in charge there gave me my first of many legal instructions: don't discuss anything about this matter with anyone at all, not even, and especially, not the other doctors named. I was offered a list of defense attorneys to choose from. I asked around as discreetly as I could and chose one well known to be a skilled defense lawyer. His first advice was: "Don't discuss anything about this matter with ..."

When misfortune strikes us, one of the greatest consolations is the emotional support we get from other victims. I would have yearned to compare notes with my colleagues who were also named. There were only two people I could look to for support whose testimony could not be discovered and presented as evidence for the plaintiff: my lawyer and my wife. Both were sympathetic and supportive. But my wife got to share the emotional burden. My wife has always been a fantastic cheerleader but I knew she was somewhat biased in my favor but there was to be no support group of my peers.

The next step was a deposition. This is a legal proceeding where the attorneys get to question the potential witnesses about all aspects of their involvement in the case, including their knowledge of their specialty, the diseases involved, the nature of their practice, their credentials, their attitudes, and anything else that might conceivable have any bearing in a trial. For the attorneys, it is like dealing the first two cards in a game of Texas hold 'em poker. The information might be useful in a trial, but it might also be useful in gauging the relative strength of one's opponent and bargaining to settle the case rather than go to court.

A deposition usually starts out with routine questions and works its way to the most critical examination of what actions or inactions are alleged to have been a breach of adequate care. As the line of inquiry proceeds, it becomes increasingly stressful. The aim of the plaintiff's attorney is to get the doctor into a rapid-fire rhythm of responding to questions without careful forethought and to lure him into offering more information that was required by the question. My deposition was definitely stressful. I had never been deposed. I was apprehensive. On the way there I kept thinking of the concluding scenes in an episode of Perry Mason when the guilty party succumbs to a withering cross-examination. The deposition room proved to be a rather comfortable non-threatening environment. All were introduced and pleasantries exchanged. The questions began. The opposing attorney was alternately pleasant and then condescending and pugnacious. My lawyer called for "time outs" when he saw I was losing my cool. The session continued and broke for lunch. The questions became more and more critical. Finally, the plaintiff's attorney shrugged and led me to think his questioning was concluded only to turn and say, "Oh, by the way ..." Then came the really accusatory series of questions. Somewhere along the way, it became clear that even if he was unable to get me to admit to some negligence on my own part, there was a potential I could be called as an "expert witness" and compelled to testify on behalf of the plaintiff that my colleagues had committed malpractice! Among the emotionally stressful experience in my life, this one is well up there; I even find my pulse quickening just writing about it.

I returned home exhausted and relieved to have gotten through it. My wife offered me a martini. I knew that the next step in the process was a trial, which was not to take place for some time, so I returned to the usual cares and pleasures of work and family. But there were always occasional reminders of the situation that would hit me in the middle of my workday. And there was a definite change in my medical practice.

With every test I ordered and every drug I prescribed, a host of potential risks and side effects came to mind, even the remote ones, and I felt compelled to enumerate them in a way I never did before. My usual confidence in knowing the proper course of management was shaken. I began to view every patient I was trying to help as a potential adversary in a suit. I even began to look at each of my oldest patient relationships with different eyes. "I know this person loves and trusts me, but might they change their mind and sue me if I make a mistake?" I asked myself. An invisible emotional curtain descended between my patients and me.

I had previously had contempt for other doctors who seemed to be practicing defensive medicine. There was a colleague whose patients occasionally came to me for a second opinion or because they didn't get along. I would review his notes and see how he documented two paragraphs of all conceivable risks and complications; I thought it was a completely misplaced sense of priorities. My attitude changed; now I understood. Now I found myself ordering more CT scans and bloodwork. The radiology report that said "consider follow-up MRI to further characterize the lesion," which I used to dismiss when it was clearly an artifact or an incidental finding, now merited that follow-up as recommended. After all, even if the procedure was expensive, uncomfortable, anxiety-provoking and the chance one in a thousand that there was something serious there, why should I be the one to take the risk of a lawsuit.

I am sure my patients suffered from my experience during that time. I was more distant. I was depressed. I felt "burnt out." I was not my complete empathetic self. I put my patients through tests that were probably "overkill." I did not spread optimism and confidence with every encounter. I left home in the morning not looking forward to the day and came home tired and unfulfilled. Fortunately, I eventually got over it, but not for some time. Here's why: Mainly, to my great relief, the suit never came to trial. It was settled within the next year. I don't know what it cost my insurance company. My lawyer advised me it was in my best interest not to know for how much and what was my share of the settlement. I also had to agree never to discuss the particulars of the case or the nature of the settlement with anyone, ever (except of course my attorney and my wife). The emotional ordeal was over. But it still took months for me to get past some of the consequences of my experience.

And only now, a few years later, this is the first time I find myself able to discuss it. Was this post cathartic? No, not really. I have already made my own peace with myself. But perhaps it will help someone else.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

QD: News Every Day--If health workers won't vaccinate, why would patients?

Health care workers' fear of flu shots has risen as an issue again.

A 3D graphical representation of a generic influenza virion’s ultrastructure, by CDC/ Doug Jordan, M.A.Refusing flu vaccination has risen among health professionals again and again. And again. And again and again.

Vaccination rates for health care workers stands at 35%, which is "a dismal rate," according to Margaret C. Fisher, MD, a pediatric disease subspecialist and the medical director of The Children’s Hospital at Monmouth Medical Center. She spoke about vaccinating adults and health care workers at Internal Medicine 2011.

The issue is as annual as the flu itself, and this time, a physician at London's Imperial College NHS Trust has jumped into the debate, tackling misinformation given within his country's own health service. He said: "A very interesting question for me is why, as health care workers, we are so confident to speak on things that we haven't actually bothered to look up the facts on.

"If you go to the GP surgery and talk to the receptionist you're quite likely to get all sorts of facts about the flu vaccines which are completely incorrect but delivered with utter confidence. It permeates through the system."

Mass General internist Suzanne Koven, MD, addressed this in her Sept. 13 column at The Boston Globe. She writes: "Interestingly, though, vaccination rates have also been low among health care workers who, presumably, understand the dangers of flu and the risk that they will spread it to vulnerable patients. Many hospitals and clinics now require health providers to either have a flu shot or submit a signed refusal. Some even offer a cash bonus as incentive.

"I think that some of the fear of the flu shot has to do with the fact that it changes every year. The vaccine is reformulated to protect against the strains of influenza projected to cause the coming season's epidemic. That makes some people uneasy."

To counter this unease among health care workers, ACP's recommendations on vaccinating health care workers and the latest Recommendations of the Advisory Committee on Immunization Practices are worth reviewing.
Wednesday, September 28, 2011

Can physician de-skilling be attributed to the use of EMRs?

Turns out there is an unintended consequence of many of the current efforts to standardize the way doctor's practice medicine. It is called de-skilling. De-skilling can occur when physicians and other providers try to adapt to standardized, new ways of doing things. Examples of such standardization include clinical based care guidelines, electronic medical records (EMRs), pay for performance (P4P), the patient-centered medical home (PCMH) requirements and so on.

Examples of physician de-skilling were revealed in a recent study which consisted of in-depth interviews with 78 primary care physicians regarding EMR use. EMRs are all about standardization: what data is captured and recorded, how data is reported, how data is used, and so on.

Over the course of the interviews, physicians in the study described significant examples of de-skilling behavior. Most indicated that valuable patient information was being lost given how physicians adapted to using the EMR. Why? The physicians believed that the EMR forced them to change how they "fed their clinical thought processes into a patient's record."

The majority of PCPs interviewed reported situations where they or specialists "cut and paste the same exact language and statements, sometimes consisting of entire narratives across different patient records" where patients had the same condition (usually a chronic condition).

The net result was that PCPs believed they were increasingly getting less patient-specific information from specialists via the EMR which hindered their ability to make informed decisions around diagnosis and treatment.

According to these same physicians, this situation did not happen with paper records. That is because paper records forced clinicians to dictate a certain amount of unique verbiage for transcription into a patient's record.

Time pressures also contribute to physician de-skilling relative to EMRs. Most EMR systems use templates that physicians must modify for each patient. Physicians in the study complained that there wasn't enough time to edit the EMR templates and then enter the proper patient information. The conclusion, according to researchers, was that "some of the docs just do the bare minimum in terms of putting stuff into the EMR. When you read what's in the record you're kind of like, what is this?''

In other words, some physicians simply didn't bother to tailor EMR templates to the needs of the patient choosing instead to simply get through the standardized template.

The bottom line is that physician de-skilling has serious implications for patient outcomes and quality of care.

Take away
Patients need to be aware of and protect themselves from instances of physician de-skilling. How can patient do that? The best way is to ask your doctor to review the patient notes section of your electronic patient record to see what you doctor entered about your condition. Is what your doctor entered accurate? Is it complete? Given that other providers will be relying on the quality of your record for treatment decisions, this is something that everyone, patient and physician, needs to be aware of.

Huff, T. Deskilling and adaptation among primary care physicians using two work innovations. Health Care Management Review. March 2011.

This post by StevenWilkins, MPH, appeared at Get 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.

Readmission after hospital discharge is not an indication of poor care

Hospitals across the country are working on quality initiatives to reduce re-admissions to hospitals. There are consultants, conferences, forums, meetings, physicians, nurses and administrators who are spending hours upon hours (and lots of $$$) to find ways to keep patients who have been discharged from being readmitted within 30 days. Why all of this activity? It is one of the quality measures that is being tracked by Centers for Medicare and Medicaid Services (CMS), and decreased reimbursement will be next if a patient is readmitted to any hospital within 30 days of a discharge. The diagnosis doesn't matter.

A new study shows all of this focus and cost may not be worth it. Readmission after a hospital discharge may not be an indication of poor care.

The study, published in the Canadian Medical Association Journal looked at 4,812 patients and had medical experts review the cases of the 649 who needed urgent readmission within 6 months. (Not one month as we are measuring). They found that avoidable readmissions were relatively uncommon. Only 16% could have been prevented by better care, oversight or management of their condition, and a tiny number of readmissions within 30 days, as we are tracking, were potentially avoidable.

This makes sense to me. They found patients who were readmitted had more previous hospital admissions and more extensive health issues. And the patients in this study were even younger than the typical Medicare patient. No one wants to be in the hospital. Doctors do not want to admit patients unless they are very, very ill. Patients who have many medical problems like heart failure, strokes, liver failure, cancer, etc. tend to decline in health as time goes on. Outpatient care and case management efforts cannot always prevent declines. The study points out that we might be measuring the wrong thing if we think it is a measure of medical quality.

They did find some urgent readmissions were avoidable. But it didn't vary by hospital ranking so either all hospitals are performing the same or it isn't really a measure of quality.

Message to CMS: Readmission cannot be determined on the basis of administrative data alone and it requires subjective judgment, detailed patient data, multiple reviewers and an analysis that accounts for differing reviewer accuracy when collating judgments. This is a big waste of money. Readmission within 30 days (or 6 months) of discharge is not a marker of quality care.

This post originally appeared at Everything Health. 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.

QD: News Every Day--Married men without children incur cardiovascular risk

Married men who have no children have a 17% higher risk of dying from cardiovascular disease after the age of 50 than men with two or more children. But whether that's because of a physical cause, a sociological effect or self-selection (sick people may choose not to have kids) isn't known.

Photo by Tracy DuBosarTo determine if the number of kids predicts cardiovascular death, researchers used data from the NIH-AARP Diet and Health Study of nearly 135,000 men ages 50 to 71 without prior cardiovascular disease who were followed-up for an average of 10 years. That study mailed 3.5 million questionnaires from 1995 through 1996 to AARP members living in California, Florida, Pennsylvania, New Jersey, North Carolina, and Louisiana or in Atlanta or Detroit. Nearly 586,000 people returned the questionnaire, which underwent follow-up surveys in 1996-1997 and 2004-2006. Results appeared online Sept. 26 in the journal Human reproduction.

Almost all (92%) men had at least one child and 50% had three or more. Nearly 3,100 men died of cardiovascular causes during follow-up for an age-adjusted incidence rate of 2.70 per 1,000 person-years. After adjusting for sociodemographic and lifestyle factors, childless men had a higher risk of death from cardiovascular disease compared to fathers (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.03 to 1.32). When pooled with men who had one child, there was still a risk (HR, 1.13; 95% CI, 1.03 to 1.23)

And, in comparison with fathers of five or more children, adjusted relative hazards for cardiovascular mortality were 1.06 (95% CI, 0.92 to 1.22) for four children; 1.02 (0.90 to 1.16) for three children; 1.02 (0.90 to 1.16) for two children; 1.11 (0.95 to 1.30) for one child; and 1.21 (1.03 to 1.41) for no children.

What isn't known is why. Biology and socioeconomic factors intermingle. There's caveats, too. Researchers couldn't account for men who were childless by choice or who had partners with fertility problems.

Still, Eric Topol, MD, FACP, a cardiologist and genetics expert at Scripps Health in La Jolla, Calif., told the Associated Press that, "I think there's something there," and "Whether it's with a pet, a spouse or social interaction ... all those things are associated with better outcomes."

But one confounder the study didn't account for is that kids induce stress, and stress is bad for the heart. As ACP Member Ves Dimov, MD, pointed out via Twitter, stress free parenting isn't possible.
Tuesday, September 27, 2011

Ruckus over the RUC

There's an interesting legal case brewing in the medical world that's worth sharing. A group of six physician plaintiffs from Georgia are suing the government (the Secretary of Health and Human Services) in a federal district court claiming damages from the fact that Medicare, the massive program that covers the elderly and disabled, fails to execute due diligence by rubber-stamping a reimbursement structure that overvalues procedural medicine over cognitive services.


Some background is in order.

It's no secret that specialists (radiologists, cardiologists, dermatologists, urologists, etc.) make higher incomes than primary care doctors (family doctors, internists and pediatricians). Obvious reasons include more training, differentiated skill, and an ability to handle specific technical and/or surgical procedures that generalists aren't able or authorized to provide.

But the non-obvious reason is a poorly publicized and shadowy body known as the Relative Value Scale Update Committee, or RUC. The RUC is a committee convened by the American Medical Association (AMA) and about two dozen medical specialty societies.

The RUC promulgates an annual report to the Centers for Medicare and Medicaid Services. The update advises CMS on the "relative value" of an extraordinarily lengthy list of medical services, including both procedures (things done to patients) and cognitive services (those done for patients with a doctor's hands, stethoscope, and brain).

The RUC has 29 members, 23 of whom come from medical specialty societies. The list is publicly available.

Critics of the RUC point out that it's a little like the Senate, in that smaller specialties gain outsized importance since representation is not proportional. This has in effect, so the argument goes, perpetuated the overvaluation of procedural skill over cognitive service. The downstream effect of this is twofold: a disparity in doctor incomes between generalists and specialists, but more importantly, ever-increasing cost of delivering health care as the premium on procedures incentivizes them.

Early comments seem to suggest that the case will have meritorious legal standing. It certainly will be interesting to see what happens as the case wends its way through the judicial system.

There's an excellent synopsis of the suit and the issues surrounding it on the Health Affiairs blog by Brian Klepper and David Kibbe, which I recommend to anyone with further interest. Here's a key paragraph that may inspire you to click over: The policy community should keep a close eye on this case, because its target is the beating heart of the American health care cost crisis. Aside from the primary care community, the plaintiffs are unlikely to have many organized supporters within a health care industry that has benefited so handsomely from the current payment regime. But the employer community as well as anyone who cares about the larger economic issues facing America should see the opportunity to largely correct a tremendous wrong in our system.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

QD: News Every Day--Gene variants in asthma diminish steroid inhaler's efficacy

Scientists have honed in on the genetic variation that explains why some asthmatic patients don't benefit as much from steroid inhalers.

In a randomized, controlled trial, researchers followed 1,041 children being treated for asthma and their parents, choosing 422 white, non-Hispanic participants and their parents for genotyping. Of this group, 118 trios (a child and the two parents) were randomly assigned to treatment with budesonide (Pulmicort). Results appeared online Sept. 26 at the New England Journal of Medicine.

Investigators identified a variant in the glucocorticoid-induced transcript 1 gene (GLCCI1), rs37972, which was associated with a decrease in FEV1 in response to treatment with inhaled glucocorticoids.

An editorial noted that, "The clinical effect of the SNP [single-nucleotide polymorphism] is appreciable but not overwhelming." After treatment with inhaled glucocorticoids, participants who had two copies of rs37972 and rs37973 had a mean (±SE) increase in FEV1 of 3.2±1.6%, as compared with 9.4±1.1% for those with no copy of the variant. About 16% of the population will have two copies of the genotype responsible for the limited response to inhaled glucocorticoids.

The editorial pointed out that the next step must be clinical trials to determine whether knowledge of this information leads to better clinical outcomes. The author stated, "If personalized medicine is going to become a reality, we need to design and execute these critical trials."

The study was also presented at European Respiratory Society Congress in Amsterdam. In other news from the conference:
Maternal workplace exposure influences asthma. 42,696 children from the Danish National Birth Cohort were studied for the association between their mother’s occupation during pregnancy and asthma prevalence by age 7. The main focus of the study was on the effect of low molecular weight agents, such as synthetic chemicals and natural substances found in vehicle parts, furniture, shoe soles, paints, varnish, glues and wood-derived products. While 15.8% of the cohort had asthma, of the children whose mothers were occupationally exposed to low molecular weight substances, 18.6% had asthma.

Moderate alcohol use can diminish asthma.19,349 twins between the ages of 12 and 41 answered questionnaires over a period of 8 years to compare alcohol intake with the risk of developing asthma. Less than 4% of those who drank 1 to 6 units per week developed asthma. People who rarely or never drank had 1.4 times the risk, and heavy drinkers had 1.2 times the risk. Also, beer was associated with an increased risk of asthma when compared with no preference.

Belly fat associated with asthma. Researchers followed 23,245 adults without asthma, aged 19 to 55 years, for 11 years. Body-mass index was recorded with waist circumference to test overall obesity and central obesity, respectively. People who were centrally obese but not overall obese were 1.44 times more likely to develop asthma. People who were both centrally obese and obese overall were 1.81 times more likely to develop asthma.
Monday, September 26, 2011

All in for Crestor

The American Heart Association will be holding its annual meeting this November. just posted the announced "late-breaking" clinical trials. These are the big name trials that usually grab a lot of headlines. One of the trials is the AIM-HIGH trial which showed that Niacin didn't really do much in patients whose bad cholesterol or LDL was controlled with a statin (see my post What to do about Niacin?)

178/365 All In by thebarrowboy via Flickr and a Creative Commons licenseAnother very important study will also be presented that same Nov. 15: Comparison of the Progression of Coronary Atherosclerosis for Two High Efficacy Statin Regimens with Different HDL Effects: SATURN Study Results. The SATURN study is the AstraZeneca (makers of Crestor) study comparing high dose Crestor (40 mg) with high dose Lipitor (80 mg).

Patients in the SATURN study will have known cardiac disease as indicated by a need for coronary angiography (angiogram) and angiographic evidence of coronary disease. The main end point is IVUS-assessed change in the percent atheroma volume in a greater than 40-mm segment of a single coronary artery, which is a "doctor" way of saying they are going to look for plaque buildup in the artery. This is the same end point used in the famous (or infamous) ENHANCE trial which showed that adding Zetia to simvastatin (zetia + simvastatin = Vytorin) did absolutely nothing to plaque buildup (Vytorin and Zetia: What to do now?)

What's interesting about SATURN is that the LDL lowering properties of the highest doses of Crestor and Lipitor are about the same. However, at those doses Crestor raises the HDL or good cholesterol by about 8% where Lipitor only raises HDL by 3%. Other studies have shown that plaque buildup in the arteries (atherosclerosis) that causes heart attacks and strokes, is not just about LDL, but also about HDL. Other studies looking at high doses of Crestor when compared to placebo show that it can prevent plaque buildup and possibly even lead to regression. The Lipitor data on this is less robust.

The timing of the results at the AHA is particularly interesting, since it will coincide with Lipitor going generic. Zocor, or simvastatin, has been generic for a while, and works well in many patients. However, patients requiring more aggressive reduction in their cholesterol will not meet their goals on simvastatin, and high-dose simvastatin is associated with side effects, which prompted a recent FDA warning. (See Don't Take High Dose Simvastatin). Thus, the need for a generic potent statin like Lipitor is huge. However, this could mean that insurers will make it very, very difficult for patients to get Crestor, unless SATURN proves that high dose Crestor compared to high dose Lipitor significant reduces plaque buildup in high-risk patients.

Therefore, the SATURN trial is really a huge gamble for AstraZeneca. When Merck's ENHANCE trial showed that Vytorin didn't really do more than the generic statin, prescribing rates dropped precipitously. Crestor likely faces the same fate if SATURN turns out to be a negative study.

Matthew Mintz, MD, is a Fellow of the American College of Physicians. He is board certified in internal medicine and has been practicing for more than a decade. He is also an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients. This post originally appeared at Dr. Mintz' Blog. Conflict-of-interest disclosures are available here.

QD: News Every Day--Dermatologists head to Sun Belt to practice

Dermatologists spend their days telling patients to avoid the sun and their careers striving to practice in it. They're leaving the Midwest and mountain states to practice in the southern and western U.S.

To evaluate the migration patterns of dermatologists from residency to clinical practice, researchers reviewed data from the American Academy of Dermatology's membership database. They looked at 7,067 dermatology residents who completed training before 2005 and were actively practicing in 2009. Results appeared at the September issue of the Archives of Dermatology.

Most graduates from Middle Atlantic and Pacific census divisions relocated within 100 miles of their residency. But residents from the Mountain census division and the Midwestern and Southern regions were substantially less likely to stay put. The Midwest retained the lowest proportion of its trainees (51%) and the South and West experienced the largest influx of residents who'd graduated from the Midwest and the Northeast.

Dermatologists certainly aren't the only specialists to flock to the most desirable locations, and it's not the only specialty that creates a shortage of care when it happens. The authors acknowledged that it's tough to suss out an individual's reasons for traveling long distances to practice. After all, who knows who is returning to the family homestead after a long time away, or is following a spouse somewhere relevant?

Still, the authors concluded, "As the field of dermatology continues to struggle with a maldistribution of its workforce, the association between training location and practice location is highly variable. However, certain regions, and particularly certain training programs, have much more consistent graduate migration patterns, with some far more likely to produce a widespread diaspora and others more likely to populate nearby communities."
Sunday, September 25, 2011

Will wireless capsule endoscopy replace colonoscopy?

Most of born several decades ago recall the futuristic book Fantastic Voyage by Isaac Asimov, where a miniaturized crew traveled through a human body to cure a scientist who has a blot clot lodged in his brain. Ironically, miniaturized medical care is now upon us while books are at risk of becoming obsolete.

I hope that gastroenterologists won't become obsolete, at least until my last kid graduates from college.

I perform an amazing diagnostic procedure called wireless capsule endoscopy (WCE), when patients swallow a camera. Once swallowed, this miniaturized camera takes its own fantastic voyage through the alimentary canal. The test is used primarily to identify sources of internal bleeding within the 20 feet of small intestine, which are beyond the reach of gastroenterologists' conventional scopes. I have performed over 200 of these examinations, and I am still awestruck when I watch a "movie" of someone's guts. While most examinations do not reveal significant findings, I have seen dramatic lesions that were bleeding before my eyes. WCE can crack a cold medical case wide open.

Here's a typical view of the small bowel as seen by the cruising camera.

Up to now, cameras are used only diagnostically, but this will change. In other words, at present, the camera can only visualize. Prototypes are being developed that can equip cameras to take biopsies of lesions and to stop bleeding that is encountered on their journey. Physicians will be able to guide cameras in real time to perform diagnostic and therapeutic tasks. Once perfected, a physician on the west coast could be directing a camera that is voyaging inside a Manhattanite. (Aren't most movie directors on the West Coast?) Amazing stuff. Of course, this technology may also be used by other medical specialties to search out and destroy diseases in their organs of interest. It will certainly have applications beyond the medical arena.

The capsule endoscopy folks have been trying to use their technology as an alternative to colonoscopy. This is a tough sell to patients who must endure a camera prep that is more vigorous than the routine torture that we gastroenterologists require prior to a colonoscopy. In addition, since the camera is only diagnostic, if a polyp is encountered, the patient would then enjoy the delight of a future colonoscopy to remove it. The latest advance in this area is a self-propelled camera that is inserted into the rectum and then guided by remote control by a physician.

When I read about the self-propelled capsule, I realized that I have committed a grievous parental miscalculation. I have tried to restrict and discourage our kids from playing video games, which I was certain wasted time and destroyed neurons. How wrong I was. These were the precise skills that would have permitted them to become medical pioneers. I have closed off many professional options for them from my misguided zeal to encourage them to pursue silly activities, such as reading.

How will gastroenterologists react if a 'camera colonoscopy' becomes ready for prime time? Perhaps, a future generation of colon cameras will be able to remove or destroy polyps and other lesions? Will we willingly surrender our colonoscopes to serve the greater good? We might do what many of us do in our bedrooms and our living rooms. We may fight with other medical specialists, or even technicians, as to who gets to hold the remote control.

This post by Michael Kirsch, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Friday, September 23, 2011

New colonoscopy recommendation makes gastroenterologist consider his options

The right side of the colon seems to be the Achilles heel of colonoscopy because polyps there tend to be flat and harder to find, and we confer the least protection from later colon cancer in that zone.

A recent article summary in Journal Watch Gastroenterology concludes that when we see a right-sided colon polyp, we may have missed another, so we should go back and look again.

This provocative recommendation represents a major change in the way we normally perform colonoscopy. But the issue is, and always has been, how to identify and remove all polyps from the colon.

So the questions I have for you are:
1) Should we routinely reexamine the right colon in everyone, only those with a polyp, or no one?
2) Have you already changed the way you inspect the right colon, or will you now?
3) If you do inspect the right colon differently, do you use retroflexion, repeat examination, or narrow-band imaging?

I look forward to your response.

This post by M. Brian Fennerty, MD, appeared at Get 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.

All the information is in the computer

Disclaimer: This is a hypothetical case. Any resemblance to anyone is purely coincidental.

Students learn about patient centered interviewing and focusing on patient problems and complaints. That is the point of history of present illness (HPI). When they come to work with a primary care provider, who has know his/her patients for a long time, some of these question can be irritating to the patient who expects the physician to remember everything about their health history.

The HPI helps when approaching a patient with a new problem. Students are often not familiar with the patient who has five serious chronic problems but no complaints. They start by asking something like, "So what brings you in today?" and they get something like "Oh, this is just a follow up. I am fine!" and then they don't know what to do next.

Part of the problem is that many medical students get only an acute exposure to chronic diseases. They do an eight-week rotation in internal medicine where they almost never see the same patient again.

Recently I had a patient who came in to establish care. She was the first patient of the day and she was 15 minutes late. I had come in earlier than usual as I knew I had a third-year student with me in clinic. Because of these reasons, I had extra time to review her electronic health record (EHR) data in some detail. She had received all her care at our institution, and this meant all her data was in one system.

The student was very bright and very comfortable with history taking but new to EHRs. The previous day, she had faced the typical patient scenario, "Why are you asking me all these questions? It's all there in the computer!"

After that last encounter, we had discussed how a lot of information can be gleaned from the EHR. So we had decided to spend some time going over the strategy of using the EHR prior to seeing the patient.

We started off by looking at a patient summary screen (a snapshot of her problem list, medications and health maintenance alerts). We saw that she had the following issues noted in the EHR by her previous physician:
1. Hyperlipidemia
2. Goiter
3. Smoker
4. Hypertension

Her medications included
1. HCTZ 25
2. Pravastatin 40

So in this patient we went over her chronic issues (problem list) and dug into each one to see what we could glean from the EHR. This is how the conversation went:
1. Let's look at the hyperlipidemia. What would you want to know?
--last lipid level
--target LDL (how do we calculate this?)
--what medication, dose, is she compliant, tolerating?
--liver test results
--diet and exercise
So we click on Chart review >>; Lab results>> Select the last 2 lipid panels >> view in table form >> find that her LDL was about 150 one year back. We discuss ATP III >> go to the ATP calculator online >> put in her risk factors >> calculate that her LDL should be less than 130 mg/dL. We assume that whoever ordered that last lipid panel must have done something when the LDL came back above the target. Go to Medication tab >> medication history >> sort by therapeutic class >> look for lipid lower meds >> find that she used to be on pravastatin 20 mg and had been increased to 40 mg after the date of the lab. Did that work? Lab results >> see that lipids and ALT had been ordered for three months after the change in dosage but were not done. So we create one agenda item: Find out if she is taking the 40 mg dose, and check lipids on that dose.

I recall reading about the new study in the Journal of the American Medical Associationon the dietary portfolio (oatmeal, soy and nuts) being better than just following a low-saturated-fat diet at lowering cholesterol. Find it in Google Reader easily and share with student. So we create a second agenda item: Discuss diet with patient and discuss with her this study.

2. Goiter: What questions do we have?
--Has this been worked up?
--What was found?
--What was done?
--What is her thyroid status?
--She is not on any meds, so is she euthyroid?

So we click on the problem "Goiter" in the EHR and find that it was first noted in 2007. Chart review >> Imaging>> USG thyroid >> has one large nodule and rest diffusely enlarged. D/w student what she would do>> FNA >> Who does this? Endocrinology>> chart review >> Encounter tab >> sort by department >>Endocrinology >> saw them in 2008 >> had an FNA done>> Lab results tab>> Sort by test >> Surgical pathology >> Thyroid bx>> Benign. Also check last TSH >> low normal 2 years back. So we create a third agenda item: Update problem list with this information so next physician does not have to do this again! Another agenda item: Ask also about symptoms and recheck thyroid-stimulating hormone levels.

3. Smoker: What would you want to know?
--Is she still smoking?
--If so, is she interested in quitting?
So we create an agenda item to ask these questions.

4. Hypertension: What would you want to know?
--What is the blood pressure today?
--Is she taking her medication? Are there side effects?
--How has her control been?
--Any evidence of end organ involvement?
In EHR to go graphs>> BP >> see that she is usually <140/80 over last four years. Chart review >> Cardiology>> Echo >> none, EKG >> normal (no evidence of LVH). Chart review >> Lab results >> BMP>> Creatinine normal, K normal; UA >> no Hb or protein. So we create an agenda item: Ask about home blood pressure measurements, does she have a machine, do cardiovascular exam for murmur, gallop, heave, bruit, pulses and look at her fundus.

The student looks at me amazed! She did not know the EHR could hold the answers to so many questions. I tell her how she can create her own agenda before going into the exam room. Once she has elicited the patient's agenda and addressed it, she needs to cover the items on her own agenda. Hopefully both the agendas are the same. Hopefully there is time to cover both the agendas.

We have spent 30 minutes discussing and reviewing all these issues. We are lucky we got an early start and the patient was late!

So what is the point of this story?
1. EHRs can hold an amazing amount of important information
2. Getting this information out of the EHR takes a lot of time, clicks and knowledge of where to find this information.
3. These benefits are visible when all the data is in one system. If the consultants and labs and imaging were all done at different places, this would not be possible. Even when external reports are scanned in, this data is not easily accessible. As we develop electronic data interfaces this should not be a problem.
4. Some patients expect that just because all the information is in the computer, it is also in the physician's brain! Wish they could realize how much effort it takes to dig all this information out.
5. As physicians use EHRs and spend time reviewing and summarizing the information, they should take time to encode it in a way that makes it easy for the next provider or the subsequent visit.
6. Students learn how to get the history from the primary source but will also need to get comfortable getting the data from the EHR in a meaningful manner. While looking up the information in the EHR prior to talking to a patient can create a huge bias and a kind of filter bubble, it is a great way to look up chronic problems.
7. The time that it takes to review all the information occurs outside the exam room and it can become non-reimbursed care. Doing this review is very important for patient care. Will this become a non-issue once we move to accountable care organizations?

Addendum 8/28/2011: Link to G+ discussion on this post.

Neil Mehta MBBS, MS, FACP, practices internal medicine at a large tertiary care hospital in Ohio. He is also the Director of Education Technology (Academic Computing) for his medical school and in charge of his hospital system's home grown Learning and Content Management System. He is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management. This post originally appeared at Technology in (Medical) Education.

QD: News Every Day--No evidence for ECG screening in low-risk patients

Electrocardiograms (ECG) aren't effective as a general screening tool in low-risk patients, despite their prevalent use, according to updated recommendations from the U.S. Preventive Services Task Force (USPSTF).

While some cardiac abnormalities found on resting or exercise ECG were independent predictors of future cardiovascular events, there's still no evidence that ECG findings better classified patients into meaningful risk groups than did traditional risk factor assessments. No studies have compared clinical outcomes or use of risk-reducing therapies between persons who did and did not receive screening.

The USPSTF updated recommendations from 2004, this time around, focusing on studies that adjusted for traditional cardiovascular risk factors, performed meta-analyses, and evaluated whether screening with ECG in improved risk reclassification. Their findings appeared in the Sept. 20 issue of the Annals of Internal Medicine.

The Task Force reviewed 63 prospective cohort studies that evaluated the clinical significance of abnormalities found by resting or exercise ECG. Abnormalities on resting ECG (ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation) or exercise ECG (ST-segment depression with exercise, chronotropic incompetence, abnormal heart rate recovery, or decreased exercise capacity) were associated with increased risk (pooled hazard ratio estimates, 1.4 to 2.1).

But, no randomized, controlled trials or prospective cohort study evaluated clinical outcomes or use of risk-reducing therapies after screening versus no screening, nor did any study estimate how accurately resting or exercise electrocardiography classified participants into high-, intermediate-, or low-risk groups. No studies evaluated how screening affects use of lipid-lowering therapy or aspirin.

Evidence on harms was limited, but direct harms seemed minimal (for resting ECG) or small (for exercise ECG), the researchers wrote. There were no direct studies on the harms found from testing or from follow-up testing, although researchers noted the general estimated complications associated with angiography or revascularization procedures (rates of angiography after exercise ECG ranged from 0.6% to 2.9%), as well as the possible cancer risks of exposure to coronary angiography, computed tomography angiography, and myocardial perfusion imaging.

ACP Member Michael S. Lauer, MD, of the National Heart, Lung, and Blood Institute, told Reuters that, "There's a general belief that prediction means prevention. But we see, over and over again, that this is not necessarily true."

If an electrocardiogram isn't in your immediate future, you could consider this as a preventive measure, albeit one that the U.S. Preventive Services Task Force hasn't considered. As Sean Khozin, MD, points out, this is the shirt you want to wear if you ever need CPR.
Thursday, September 22, 2011

Evidence-based recommendations triggered accusations of euthanasia

I'm flashing back to summer of 2008. I'm looking forward to August 5, the day that I'll no longer be a faceless bureaucrat. This was the day that the U.S. Preventive Services Task Force (USPSTF) issued its new recommendations on screening for prostate cancer, recommendations I've labored on as a federal employee for the past year and a half.

For much of 2007 I combed the medical literature for every study I could find on the benefits and harms of prostate cancer screening. In November of that year I presented my findings to the USPSTF, a widely respected, independent panel of primary care experts. They discussed and debated what the evidence showed and then voted unanimously to draft new recommendations. I didn't get to vote, but it has been my job in 2008 to shepherd the draft statement and literature review through an intensive vetting process and to finalize both.

As August 5 approaches, my colleagues in public relations warn me that the last time the USPSTF said anything about prostate cancer screening, the phones started ringing off the hook. I'm not-so-secretly hoping that the same will happen this time.

And I'm not disappointed! After we release the statement, my normally placid government agency buzzes with excitement. In addition to sparking front-page stories in major national newspapers, the story brings our PR office "hits" from television, Internet and radio outlets all over the country. With the volume of requests far exceeding what the Task Force's press-liaison person can handle, I offer to pitch in. I give two newspaper interviews and debate a respected urologist on a live radio call-in show. My colleagues cheer me on. I forward the radio clip to my friends and family.

The new recommendations surprise many people: They say that men age 75 and older should not be screened for prostate cancer.

Why not?

Because there's no convincing proof that the prostate-specific antigen (PSA) blood test, the one used to detect early prostate cancer, actually saves lives. Most abnormal PSA tests do not actually indicate cancer, and up to half of true prostate cancers detected with the test would never have caused health problems if they'd gone undetected.

On the other hand, there's lots of evidence that the PSA test causes physical and psychological damage. Abnormal tests lead to prostate biopsies, operations and other treatments whose adverse effects range from anxiety to surgical complications to death. For younger men with decades of life remaining, these adverse effects may be worth the potential benefits; in men aged 75 and older, they almost certainly are not.

I soon learn that cancer recommendations, like cancer screening tests, come with their own adverse effects.

Comments pour into health blogs and the editorial pages of my favorite newspapers, accusing the Task Force, and me personally, of "ageism" and "taking the first step toward government-sponsored euthanasia." The systematic review I worked so hard on is trashed as a "shoddy meta-analysis" (although it's neither shoddy nor a meta-analysis), and many elderly men and their spouses lambaste us for being in league with heartless insurance companies.

I realize that this report has hit a nerve, the one that distrusts the health care system and that lacks faith in government. Cancer inspires more fear and anxiety than many other diseases. People worry about being denied access to cancer care, even care that hurts more than it helps.

I'm most wounded by one comment, which says that those responsible for developing the guideline can't possibly understand what it's like to have, or to care for someone with, prostate cancer.

This one really pains me because I do understand.

I remember only too well a 75-year-old patient--I'll call him Kendall--whom I met during my residency training in Lancaster, Pa., an area best known as Amish country. Kendall wasn't Amish, yet he hadn't seen a doctor in decades. Before I met Kendall, he'd been hospitalized with bone pain and a PSA of over 5,000 (more than 4 is considered suspicious) and had been diagnosed with advanced, metastatic prostate cancer.

Kendall responded dramatically to a course of hormone-deprivation therapy and returned home. As I learned over the course of our outpatient visits, he was a man of few words but big gestures. At the end of our time together, he'd stand and clasp my right hand tightly in both of his, saying, "See you in a few months, doc."

Later, when the cancer and its awful pain returned, and Kendall became weaker, he was one of my favorite home-visit patients.

The end came surprisingly quickly. A hospice nurse paged me with the news that Kendall was in the ER, disoriented and combative. I rushed over and tried to soothe him as we ran tests, hoping in vain to find something we could fix. Soon afterwards, he was transferred to an inpatient hospice. He died a few days later.

Would PSA testing and earlier detection have spared or prolonged Kendall's life? Given the aggressiveness of his cancer, I doubt it, but it's hard to know for sure. And I admit that Kendall often came to mind as I was working on a recommendation to stop PSA testing at age 75. If he'd ever bothered to visit a doctor, maybe he would have been one of the few men helped by such testing, rather than one of the many harmed. I'll never know.

My colleagues and I labored for months to present a thorough and accurate review that would help the USPSTF make sensible recommendations aimed at doing the most good and the least harm. We performed our work without considering health care costs or political fallout.

I'd hoped that August 5 would free me from being labeled a faceless bureaucrat. Ironically, it ended up tarring me as a heartless one.

Prostate cancer causes a lot of suffering, I know. In the face of that, it's tempting to try and detect it early, to "do something." But for now, unfortunately, our best science tells us that doing something to a man older than 75 is likely to do more harm than good.

For Kendall's sake and for my own--for I hope to be 75 myself one day--I wish it weren't that way.

I wish that on August 5, 2008, I'd had better news to share.

And I wish that everyone had understood that.

This post by Kenny Lin, MD, appeared at Get 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.

Reducing costs by better integration of palliative care in cancer treatment

We're up to point 9 on the list, and nearing the end, on my review of the article "Bending the Cost Curve in Cancer Care" from the May 26 New England Journal of Medicine. The suggestion from the authors, Drs. Smith and Hillner, is that doctors better integrate palliative care into usual oncology care.

The authors start this important section well: We can reduce patients' fears of abandonment by means of better-integrated palliative care. This topic is fraught with misunderstanding given the references to "death panels" during the recent debate concerning health care legislation ...

Here they're on target: Some patients think, mistakenly, that inclusion of palliative care in their treatment means their doctors are throwing in the towel. I've known some oncologists who think the same, who perceive palliative care as a last resort.

The truth is that palliative care, which aims to relieve symptoms, can be implemented at any point in the treatment of disease.

The authors go on to provide data that cancer patients who receive palliative care live just as long, or longer, than those who don't, and that their medical bills are lower. The issue I have here is their choice of emphasis on a published study of the Aetna Compassionate Care Program in which nurses identified patients for palliative care by administrative claims, "thus bypassing the oncologist." Evidently this strategy led to a doubling of hospice referrals and other possibly good effects.

Besides that the cited study was authored by employees of an insurance company, which I find unpalatable, the concept of having nurses do the referrals deflects the issue: that oncologists talk about palliative care with their patients, directly. Relying on nurses to carry out these conversations would, understandably, contribute to a sense of abandonment, even if the nurses do the job perfectly. A critical role oncologists is to communicate about treatment care options, part of the cognitive work considered in point 8 of this discussion.

But the main idea, that doctors should integrate palliative care into their cancer patients' treatment planning, earlier, and as a supplement and not a replacement for potentially curative or tumor-shrinking strategies, is right on.

This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.

QD: News Every Day--Belt-tightening continues for medical practices

Medical practices cut general operating expenditures 2.2% in 2010, while general operating costs rose by 52% since 2001, exceeding revenue gains during that time.

According to the Medical Group Management Association's (MGMA) Cost Survey for Multispecialty Practices: 2011 Report Based on 2010 Data, total medical revenue in multispecialty practices not owned by hospitals or integrated delivery systems increased nearly 46% since 2001 and 8.5% since 2009, likely as a result of trimming operating expenses, MGMA stated in a press release. Spending on furniture and equipment expenses decreased 23% since 2010, and drug supply costs decreased 8.5 %. Expenditures rose since last year for total support staff (4.8%) and medical and surgical supplies (7.4%).

Chart courtesy of MGMAResults show that medical practices are not spending as much money as they were last year, which isn't necessarily a good thing, commented MGMA president and CEO William F. Jessee, MD. Practices are steeling themselves against proposed Medicare payment cuts by reducing operating expenses, and renegotiating rates with vendors, supply companies and insurance carriers. "There is only so much more practices can do to cut expenditures without inhibiting their ability to run a successful, innovative practice," he said.

The survey includes data from more than 44,000 providers and 2,000 groups.
Wednesday, September 21, 2011

Encourage earlier mammograms for women with a family history of breast cancer

Somewhere along the line I learned to encourage women with a family history of breast cancer to begin getting mammograms at an age 10 years prior to when their mother was diagnosed and to encourage their daughters to begin getting mammograms at an age 10 years prior to when they themselves were ever diagnosed.

I learned this prior to the discovery of BRCA genes. It was a trend that had been noted among women with strong family histories. The new study (see full reference below) in the journal Cancer verifies that genetic breast cancers show up earlier in the next generation on average by 8 years.

The study looked at two generations of families with the BRCA gene to assess the age at diagnosis. Using the pool of 132 BRCA-positive women with breast cancer who participated in the high-risk protocol at The University of Texas MD Anderson Cancer Center (Gen 2), 106 women could be paired with a family member in the previous generation (Gen 1) who was diagnosed with a BRCA-related cancer (either breast cancer or ovarian cancer).

The median age of cancer diagnosis was 42 years (range, 28-55 years) in Gen 1 and 48 years (range, 30-72 years) in Gen 2 (P less than .001). In the parametric model, the estimated change in the expected age at onset for the entire cohort was 7.9 years (P less than .0001). Statistically significant earlier ages at diagnosis also were observed within subgroups of BRCA1 and BRCA2 mutations, maternal inheritance, paternal inheritance, breast cancer only, and breast cancer-identified and ovarian cancer-identified families.

It is reasonable to encourage these women with significant family history of breast cancer to begin surveillance at an earlier age than the general population.

Earlier age of onset of BRCA mutation-related cancers in subsequent generations; Litton JK, et al; Cancer 2011; DOI: 10.1002/cncr.26284.

Breast Cancer Patients With BRCA Gene Diagnosed Almost Eight Years Earlier Than Generation Before; Science Daily, September 12, 2011

Mom's Cancer Shows Up Earlier in Daughters; Michael Smith, Dori F. Zaleznik, MD; MedPage Today, September 12, 2011

This post by Ramona Bates, MD, appeared at Get 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.

Price lists needed for medical tests

I am smacking myself on the forehead and saying, "Why didn't I think of this?" Richard Parker, MD, Medical Director at Beth Israel Deaconess Medical Center, has sent out a list to his physician colleagues of 56 common medical tests and procedures. What is revolutionary is that there are prices next to each item. You non physicians may be surprised to know that we doctors have no idea what the tests or drugs we order actually cost. Unless we get billed as a patient, we are as clueless as you are.

As I wrote before, the ostrich excuse just won't fly any more. We all need to be aware of the cost of care and have skin in the game. Some will argue that price can't be the only driver. I've heard physicians say you can't compare one price to another because "quality" costs more. I say prove it. If you have a quality product or are a higher quality physician, show us the results. What are your outcomes? Is your customer service better? Is it worth the higher cost you charge? Let's be transparent and let the patient determine what something is worth.

Separate from physician fees, however, is the variability and wide ranges in costs of similar tests. I hear from my patients who have high deductibles and pay first dollar coverage for their health care. I frequently order a screening vitamin D test and found out the patient was billed as much as $200 for one test. A colonoscopy can cost as little as $1,100 and as much as $2,600. That is a huge price variance. What about ultrasounds and MRI scans? The variation in price is astounding.

Dr. Parker says he wants doctors to think about the cost of the things that they are doing. "We're not saying don't give patients what they need," says Parker. "We'll fight hard to get them what they need, but please don't give them what they don't need. We just can't afford that anymore."

I have been calling for transparency in pricing for a long time. Patients and physicians need to know what things really cost. Maybe I'll try what Dr. Parker did for my area ... if I can find out the prices, that is.

This post originally appeared at Everything Health. 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.

QD: News Every Day--Cancer research good for survival, and the economy

High-tech cancer research has led to more people surviving for longer, and calls for continued funding point out not only that it's good for people, but it's good for the economy, too.

With a nod toward the 40th anniversary of President Richard M. Nixon signing the National Cancer Act, the American Association for Cancer Research released the AACR Cancer Progress Report 2011 outlined several key advances that have happened since his presidency in diagnosing, treating and eventually preventing cancer.

Between 1990 and 2007, death rates for all cancers decreased by 22% for men and 14% for women, resulting in 898,000 fewer deaths from the disease, the report said. Today, more than 68% of adults live 5 years or more after their first diagnosis, up from 50% in 1975. There are more than 12 million cancer survivors in the U.S. today, and 15% were diagnosed more than 20 years ago.

While surgery, chemotherapy and radiation have all developed into standards of care, the report looks toward advances in understanding the molecular forces that drive disease, and how it will lead to personalized care.

Among other fields of research, the Human Genome Project has identified more than 290 genes related to cancer. This has led, in turn, to finding two key classes of cancer genes, oncogenes that drive uncontrolled cell growth and tumor suppressor genes that protect the genome.

And, the report continued, whereas the organ of origin used to define what kind of cancer a patient has, now it's defined by the molecular changes that are occurring. (ACP Internist columnist W. Gregory Feero, MD, PhD, Special Advisor to the Director of the National Human Genome Research Institute, examines this topic in the September issue.)

Now that this is understood, the report continues, researchers have developed targeted therapies are far less damaging than chemotherapy. There are now 32 such drugs, such as imatinib (Gleevec), for chronic myelogenous leukemia, which now offers a 5-year survival rate of 95%.

AACR noted in a separate press release that $3.8 billion in federal funds invested in the Human Genome Project from 1988 to 2003 helped drive $796 billion in economic impact and generated $244 billion in total personal income.

AACR called for Congress to provide the National Institutes of Health and the National Cancer Institute with sustained budget increases of at least 5% above the biomedical inflation rate.

Append the economic benefits of research onto the key issue of the war on cancer is topical, considering the current political environment that is clamoring for jobs and acting so cynically toward providing care for the sickest individuals. What would Nixon have thought of it all?
Tuesday, September 20, 2011

Doctors as laborers

Thought question: Who does your doctor work for?

You, right?

But does your doc work for herself or is she an employee? If the latter, is she an owner/employee, or just a hired gun?

You may have read elsewhere that doctors who are in business for themselves, a proud bunch, are finding it harder to survive in the highly competitive, costly and increasingly burdensome health care industry.

Flat/decreasing revenue + rising overhead = burnout and/or business failure.

Due to this equation, as well as generational shifts in how doctors are choosing to structure their lives and practices, more doctors than ever (especially those in primary care fields like pediatrics and both internal and family medicine) are taking on the mantle of employee.

And given current unemployment numbers, we're darn grateful to have jobs, and well paid ones at that.

Yet with the security of a job with salary and benefits comes a loss of autonomy, which is one thing if you work for a medical group or a hospital, which have the resources for marketing and infrastructure.

But what if the corporate boss is an insurance company?

United Health, among other market-based health insurers, is gobbling up doctors' groups to in an effort to deliver more cost-effective care to its insured patients by "managing care on the front end."

Optum, a United division, made a big splash last week by purchasing the biggest independent physicians' group in Orange County, California, in the largest such deal to date.

"A price was not disclosed," reads the Wall Street Journal article on the announcement.

I'm all for practicing the best possible medicine in the most cost-effective manner, but to me this gives too much leverage to the purse at the expense of the professional.

And where does the patient fit into all this wheeling and dealing? What about choice? The freedom to choose where you go to the doctor? How can you be certain your doctor is working for you when there are corporate dicta to control costs?

Increasingly, I worry that doctors are simply a "means of production" in the world of corporate medicine. This must be why those yeoman docs holding out in private practice continue to buck the trend.

This post by John H. Schumann, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

QD: News Every Day--Patients won't fill lipid drugs more than other classes

Patients won't fill their hyperlipidemia drugs more often than any other drug class, researchers concluded.

When broken down by therapeutic class, 13% of patients prescribed drugs for an antihyperlipidemic didn't fill the prescription in the first 30 days, compared to 11% prescribed an antidiabetic and 7% of patients prescribed an antihypertensive. Noncompliance occurred in 5% of patients prescribed medications from more than one class.

Most studies never look at who doesn't ever fill a prescription, because claims databases never record a prescription that's never filled. But researchers at Kaiser Permanente Colorado used their electronic health record system to link the script to the pharmacy and track fulfillment within 30 days.

Results appeared online at the Journal of General Internal Medicine.

The numbers broke down this way. There were 12,061 patients included, 1,142 who didn't ever fill their prescription and 10,919 who did. There were 4,721 patients prescribed for hypertension, of whom 331 (7%) didn't fill their first prescription. There were 4,607 prescriptions for hyperlipidemia, and 582 (13%) went unfilled. There were 1,521 for diabetes, of which 172 (11%) went unfilled. There were 1,212 with multiple drugs, of which 57 (5%) went unfilled.

Some other factors noted to reduce compliance included:
--race/ethnicity other than non-Hispanic white were more likely to be primarily non-adherent (Hispanic odds ratio [OR], 1.74; 95% confidence interval [CI], 1.20 to 2.52) and other race/ethnicity (OR 1.87; 95% CI, 1.28 to 2.72),
--those less than 10 years of enrollment in health insurance compared to more than 10 years (OR, 1.28; 95% CI, 1.00 to 1.62), and
--those enrolled in an insurance product other than a traditional HMO (OR, 2.56; 95% CI, 1.46 to 4.50).

Finally, researchers noted that when a non-primary-care provider prescribed an antihyperlipidemic, adherence fell (OR, 0.33; 95% CI, 0.21 to 0.50). At Kaiser Permanente Colorado, antihyperlipidemic therapy is often started by a centralized pharmacist service and monitored by physicians.
Monday, September 19, 2011

"At least it can't hurt"

One of the things that constantly amuses me is how frequently I hear from patients that their other doctor told them there was nothing wrong with them using this or that home remedy or so-called natural treatment or some other form of complementary or alternative therapy, saying "Well, at least it can't hurt."

Coming from a medical professional, ostensibly having been educated in the scientific method and the value of randomized controlled studies, such remarks to me bespeaks a surprising degree of either naivete, lackadaisical attitude, denial, or an understandable wish to gain the patient's trust and not to take away the placebo value of the treatment that the patients feel to be helping them. In my more cynical moments I sometimes suspect that the other doctor is really trying to dismiss the patient's enthusiastic recitation of the vitamin or natural remedy that they are taking so they can get on with the office visit without undue delay.

The first thing that I find so surprising about this is that so few people imagine that something they believe capable of causing significant good would be capable of causing some harm or side effect. Patients are very quick to ask if me there are any possible side effects or risks to taking medications that I recommend, but they rarely ask if there could be any side effects to this or that vitamin or "colon cleanse" or "detoxifier." Frequently, they are under the misimpression that as long as something is "natural" that it must be safe. My late father-in-law, who was a family practitioner in Brooklyn, used to become incensed at that suggestion. "Why, cholera is natural!" he would exclaim. He knew whereof he spoke, as he had seen cholera epidemics firsthand in the ghettos of Poland. My family recalls fondly the shocked stares he drew when he expressed his outrage about this notion at the top of his lungs while shopping in the natural foods market in Berkeley California with my wife.

But the thing that I find most surprising is that so many of my colleagues do take it for granted that all of these complementary and alternative medications are probably safe simply because they regard them as placebos. It seems to me a matter of logical necessity that anything capable of having an effect may cause either good or bad effects or both. Yet when I point this out to my patients they usually respond with quizzical looks. Then some of the more thoughtful ones see the point. If I have the time I relate the story of my father-in-law and how "Cholera's natural!"

I'm not saying that complementary and alternative therapies don't work. I am seeing they usually do, but not necessarily in a positive fashion.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.