Monday, April 28, 2008

Banning Pharmaceutical Companies from Medical Schools

A report recommends that the nation's medical schools ban doctors, students, and staff from accepting gifts from pharmaceutical companies.

Well it's about time. Although surveys routinely indicate that doctors believe that cannot be influenced by these small tokens and gifts, in fact, the change in behavior is quite subtle. In the same surveys, doctors feel that their colleagues are more likely to be influenced by pharmaceutical marketing than they are. As a result of these practices, doctors prescribe the newest therapy, not necessarily the most proven or most effective (note the prescribing of VYTORIN, a combination cholesterol lowering medication never proven to decrease heart attack risk). The free medication samples dropped off by a pharmaceutical representative typically go to those who have health insurance, not those who have a true need despite what we tell ourselves.

Let's get real. For patients to trust their doctors, we need to be unbiased and separate any appearance of impropriety that would violate that trust. Patients are already confused with the myriad of information and advertisements about medical therapy. They need someone who can look out for their best interest. That is our role as doctors. If this policy is adapted by the 129 medical schools, which it is expected, then perhaps the next generation of doctors will do the right thing and not get distracted or fooled by small gifts that have clouded their colleagues' professional judgment.

Wednesday, April 23, 2008

We're 42nd! We're 42nd! We're 42nd!

An analysis by a team from Harvard Public Health found that life expectancy not only may have hit a peak, but for many Americans has fallen.

Counties in the South found that more deaths were due to risk factors like smoking, obesity, and high blood pressure which caused more cancers, emphysema, and diabetes. Obviously the causes could be multifactorial. Certainly the counties with worsening life expectancy were poorer. Do those individuals have adequate health insurance or ability to get preventive healthcare? Do they have access to healthy food choices like fruits and vegetables? Can they afford them? Is there access to parks and other forms of recreation that allow physical activity or are the areas devoid of them and instead require people to drive more?

As the nation with the most financial and intellectual resources, we should do better than a life expectancy of 42 in the world. Increasingly, our country is becoming into two Americas, those that reach their full potential and those that are left behind. We need a serious system overhaul.

From the article:

  • Last September, the U.S. Centers for Disease Control and Prevention reported that U.S. life expectancy had risen to almost 78 years in 2005 -- up from 75.8 years in 1995 and 69.6 years in 1955. The United States ranks around 42nd in the world in life expectancy.
  • "The majority of these counties were in the Deep South, along the Mississippi River, and in Appalachia, extending into the southern portion of the Midwest and into Texas," Ezzati's team wrote.
  • "One of the questions we are asking is whether our ranking in the world is getting increasingly worse because we are not doing a good job of taking care of the worst-off," Ezzati said.
  • "Life expectancy decline is something that has traditionally been considered a sign that the health and social systems have failed, as has been the case in parts of Africa and Eastern Europe," said Christopher Murray of the University of Washington, who worked on the study.
  • "The fact that is happening to a large number of Americans should be a sign that the U.S. health system needs serious rethinking."
  • The study is available at doi=10.1371/journal.pmed.0050066.

Saturday, April 19, 2008

Why Patients See Us

It often takes a little illness to remind doctors what it means to be patients. At least for me. Coming home from work a few days ago, I came down with a sudden feeling of profound fatigue, muscle aches, and chills. While initially I thought it was due to inadequate sleep, it became more obvious as I began coughing up greenish phelgm and increasing pain in all of my muscles particularly in my low back and eyes.

I stayed in bed the entire day only getting up to eat a small lunch or dinner. I don't particularly like taking medications (most of my patients feel the same way) and refused to do so. It's a viral illness. It will get better.

If I wasn't a doctor, I suppose I might think it was something more serious. But my training told me that with no high grade temperature, no wheezing, no shortness of breath, it most likely was a cold. Nevertheless, it didn't make me feel any better knowing this.

So this is why patients look as us incredulously when we tell them it is a virus and there isn't any special medical treatment besides time, rest, and some over the counter medications. My family members in the past have been offered antibiotics and even prednisone for clear cases of viral illnesses. Although the well meaning doctors and nurse practioners probably felt that patients would feel better that they would be doing something, educated patients know that this behavior in fact this is not appropriate and not only drives up healthcare costs but also antibiotic resistance.

As I try to reassure myself that the periodic coughing of phelgm, the constant muscle pains and chills will pass, my better half encourages me to try some Tylenol. Tylenol? After I became a doctor, I've become more reluctant to take medications. But, really, Tylenol?

After 1000 mg of Tylenol and an hour later, I felt quite a bit better. Although I am still recovering, it just goes to show that the best medical treatment is understanding how someone else feels by being put in his shoes and the compassion given, as well as time, over the counter medication, and rest, is all one needs to get well.

Monday, April 14, 2008

Sicker? Pay More. Healthier? Pay Less.

Insurers are now asking patients to shoulder more of the costs for expensive life saving drugs than in the past as a way to manage rising healthcare expenses. Is anyone surprised? A NY Times article found that:
  • insurers abandoned the traditional arrangement that has patients pay a fixed amount, like $10, $20 or $30 for a prescription, no matter what the drug’s actual cost. Instead, they are charging patients a percentage of the cost of certain high-priced drugs, usually 20 to 33 percent, which can amount to thousands of dollars a month.
  • Private insurers began offering Tier 4 plans in response to employers who were looking for ways to keep costs down, said Karen Ignagni, president of America’s Health Insurance Plans, which represents most of the nation’s health insurers. When people who need Tier 4 drugs pay more for them, other subscribers in the plan pay less for their coverage.
  • But the new system sticks seriously ill people with huge bills, said James Robinson, a health economist at the University of California, Berkeley. “It is very unfortunate social policy,” Dr. Robinson said. “The more the sick person pays, the less the healthy person pays.”
  • Traditionally, the idea of insurance was to spread the costs of paying for the sick.
While it would be easy to blame the insurers for doing this or the employers for asking the insurers to come up with more affordable premiums, the real reason for this cost shifting is because health insurance is this country is not considered a shared responsibility among all. Specifically, the healthy buy health insurance not only for themselves but also to partially subsidize those who are ill.

Increasingly however our healthcare system is stratifying into different segments with the healthiest opting out or only paying what their true costs are. As a result, those who are sickest need to pay even more than in the past because there are no others to subsidize their costs.

Without true healthcare reform, i.e. universal coverage, these kind of stories are only going to continue. That's the real tragedy.

Friday, April 11, 2008

Knowing How To Reform Healthcare Is Easy. Doing Is Hard.

Like most things in life there is a big difference between knowing and doing. Most of us know what to do to stay healthy. Don't smoke or quit smoking. Exercise regularly. Eat a diet balanced with all of the different food groups in reasonable portion sizes. Maintain a healthy weight. Get screened for various medical problems early. One study suggested that doing these simple interventions extended life by 14 years!

Yet despite these seemingly boring yet simple lifestyle changes, there obviously there is gap between knowing and doing. About two-thirds of Americans are either overweight or obese. This trend is now affecting children. We all know what to do, but often it is we don't go about doing it.

The same applies to healthcare reform. A recent editorial in the NY Times noted that the cost of providing high quality medical care varied substantially among hospitals. The least costly were the famed Mayo Clinic and the Cleveland Clinic. The most expensive? UCLA, John Hopkins, and Mass General. The reason was that doctors at the most costly hospitals were paid fee for service. Do more and get paid more. On the other hand, doctors at the Mayo Clinic were on a salary. Health outcomes were the same. If all hospitals performed at the level of Mayo Clinic, then Medicare would save billions.

At the same time an article on the Wall Street Journal blog noted that a congressional advisory committee recommended that Medicare should pay primary care doctors more and less to specialists because of a shortage of primary care doctors, which if unresolved will result in increasing healthcare costs and worsening outcomes. In other words, pay primary care doctors more but have specialists be reimbursed less for each procedure. What will happen? Specialists will do more procedures to maintain their standard of living.

If Mayo Clinic can attract doctors and patients to their system. If doctors are salaried and patients do as well at less cost, then doesn't it make sense to have doctors paid to think instead of simply doing procedures?

Monday, April 7, 2008

Can't Trust Everything You Read on the Internet

A sad but interesting phenomenon we've all noticed in the internet age. People assume whether it is an email chain from Bill Gates and Microsoft a financial payoff only if we forward the email or other offers which are too good to be true that if it is on the internet it must be true.

Take the example of an Oregon homeowner, Robert Salisbury, who discovered strangers taking his belongings after someone but an ad on Craigslist that he had abandoned his home. Mr. Salisbury had no such intention.

  • "I informed them I was the owner, but they refused to give the stuff back," Salisbury said. "They showed me the Craigslist printout and told me they had the right to do what they did."
  • The trespassers, armed with printouts of the ad, tried to brush him off. "They honestly thought that because it appeared on the Internet it was true," Salisbury said. "It boggles the mind."
It recalls articles written about how patients use the internet to research their symptoms and ask their doctors if they suffer from a particular ailment. The challenge for many doctors is that often people don't have the experience or knowledge of whether a particular description truly fits their situation. Many doctors can empathize with this predicament as during medical school we had just enough information but not enough perspective to think we had every single neurologic, dermatologic, and infectious disease, we happened to be studying at the time.

The problem many doctors encounter is that patients simply don't believe what we tell them, because if it is on the internet, it must be true!

From the NY Times - Visits to Doctors Who Are Not in, Ever
From Time magazine - When the Patient Is a Googler

Friday, April 4, 2008

Book Review - Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

Patients with the same illness are getting more costly medical care in certain parts of the country but actually do worse. The amount of medical care delivered is driven by the number of specialists, hospitals, and technology available in the community. The more doctors and hospitals add new services and technology the more likely those expensive services are used regardless of whether patients need it but because the providers can get paid for it. When organizations and committees try to set up guidelines based on evidence or do research to see if current therapies are effective, special interests and politics kills the initiatives.

Hospitals focus on generating more business in departments which are profitable, like oncology, with newer buildings and the latest medical equipment so that they can afford to run emergency departments which continually lose money. Doctors and patients are enamored with the latest treatments and interventions which often are far more expensive, aren't better than existing therapies, and like the case of bone marrow transplant for metastatic breast cancer patients, are more lethal.

The pharmaceutical industry is intimately linked to doctor education and invariably influences which prescriptions are prescribed and market prescription medications as easily as consumer companies promote common household products. It is money not science that drives the healthcare system.

The author believes that solving the dysfunctional healthcare system requires that doctors and hospitals align themselves into integrated healthcare organizations like the Mayo Clinic, Kaiser Permanente, and the Veterans Health Administration. Unfortunately, however, because she makes such a compelling case of how each of the various providers and businesses each have a financial self interest to keep the current system going at the detriment of patient care, it is difficult to see how the transition will occur, if ever.

If you were asked to set policy for the White House, then this would be the book to get you up to speed on what makes our healthcare system the most expensive in the world and the worst at keeping us healthy. If however you are just trying to navigate through our healthcare system then the book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System would be a better bet.

Tuesday, April 1, 2008

Book Review - How Doctors Think

Fascinating read and written in the same spirit as Malcolm Gladwell's Blink. Dr. Jerome Groopman investigates how doctors make misjudgments and misdiagnoses because of their failures to understand and acknowledge cognitive limitations and errors in thought that affect all of us and unbeknownst to us. He feels that if doctors take a step back, are introspective and insightful about these deficiencies and take appropriate steps to minimize these problems, we can be better clinicians. The doctors he profiles are truly inspirational, remarkable, and masters in their fields, not only because of their medical knowledge, but because of their recognition of what it takes to be superb people and clinicians.

If there is an area of disagreement, then it is the fact that Dr. Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, but Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy it is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence. As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating. The book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System has more practical tips and suggestions on how to get the right care.

If there is a lesson to be learned, then it is that as doctors we need to understand that our thought processes can be clouded by emotions and can be limited simply because we too are human. To overcome this problem, which affects all of us, we need to be deliberately thoughtful and systematically introspective when caring for patients. As a practicing primary care doctor, I believe that we, not the patients, bear this responsibility and that I hope doctors in training are being taught this routinely in this country and that others welcome the opportunity to do better. While it should be a required reading assignment for medical students, interns, residents, and practicing physicians, better thinking doctors alone aren't going to improve healthcare quality in the United States. Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded and see that the world he trained in is far different than the world his trainees are about to enter.


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