Thursday, December 23, 2010

The Best Book on Healthcare Reform (or Surviving It)

The best book on healthcare reform or surviving it is The Innovator's Prescription: A Disruptive Solution for Health Care .  The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors, respected Harvard Business School (HBS) professor Clayton Christensen, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School Jerome Grossman, and another doctor and graduate of the MBA program at HBS Jason Hwang avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it.  They authors have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Sunday, December 12, 2010

Elizabeth Edwards, Breast Cancer, and Mammograms - Her Death a Failure of Healthcare System.

Elizabeth Edwards died recently of breast cancer at 61, leaving behind three children, Cate (28), Emma Claire (12), and Jack (10).  Described by her eldest daughter as intelligent, humorous, and witty, I'm fairly certain that she would not have wanted to leave her children at such a young age. Yet, in November 2004, shortly after the presidential election, she announced to the public that she had discovered a breast lump, which ultimately was diagnosed as cancer.  She admitted shortly after her diagnosis that at age 55 that she had not been screened for breast cancer with a mammogram for about four years.

Which is why the recent report from the San Antonio Breast Cancer Symposium, done annually in December, is particularly worrisome.  The study period between 2006 to 2009 found these screening rates to be lower rates than the past.  Only 50 percent of women eligible to be screened for breast cancer actually did so.  That number improved slightly to 60 percent with women receiving two mammograms over a four year period.

In other words, 40 percent of women, who should get mammograms, aren't getting them.  

Just like Elizabeth Edwards.

Is it personal choice?  A cost issue?  Or lack of time?  Lack of understanding?  While experts debate, I'll tell you.

It's a lack of time and lack of understanding.  Everyone is incredibly busy.  Given a choice, patients will do the right thing if they are nudged to do so.  In fact, they want doctors to help guide them to the correct choice.  Elizabeth Edwards certainly as a mother and professional woman had the financial resources and intelligence to know the importance of annual mammograms starting at age 40, yet didn't do so.  Perhaps she didn't think she was at risk.  Maybe she was focused on her children and husband and didn't care for herself as much as she should have, a common trait for many mothers.

The question is was she reminded of her options?  If she was a patient in my practice, she would have benefited from a team effort that constantly worked to keep her healthy.  At every office visit, whether with a primary care doctor or a specialist, every patient at every check-in received a personalized checklist that is age appropriate.  Ms. Edwards would have seen on her checklist that she was overdue for her mammogram.

To make it incredibly easy to get it done, all of the medical offices that her doctors work at have a radiology department with mammogram machines.  To make it even easier, patients can walk-in to have them done.  No appointments needed.   No paper work required.  She simply would have finished up with her doctor, checked in with radiology, and had her mammogram.

If by chance she was busy and otherwise healthy and hadn't seen a doctor face to face, but was overdue then she would have been notified by mail at least three times to remind her of that fact.  A team of healthcare providers use the electronic medical record to find which women are overdue, contact them, and then check again to see if the mammogram was done.  If after a few attempts if there still was no response, her primary care doctor would get a message to call her, just to make sure she fully understood the choice she was making.  If she still declined, while that would not be the medically advisable, her decision would be respected.  After all, she is an adult and would have been fully informed about the pros and cons of her decisions.

It's likely, however, that instead of a four year absence, she would have opted for a mammogram.   It would have shown an abnormality months before she actually felt a lump.  Chance of recurrence is much less when breast cancer is caught at a non-palpable stage.

Despite all of the advances in oncology and chemotherapy treatments, the biggest decline in breast cancer deaths over the past 25 years was due to mammogram screening.  Though the new healthcare reform bill which make preventative services like screening for cancer free, that isn't enough.  If people are too busy to remember, much like doing the right thing for retirement planning, they won't do what is in their best interest, even if it is what they would have done if they only had time.

In other words, it isn't about the individual as much as enabling the individual to do the best for herself by designing the system to get the best outcome.  It is true in retirement planning and automotive and road design as it is in healthcare.

I don't believe that if she had such a healthcare system in place to help her stay healthy and well that her life would have ended this way.  While the system I describe exists today in California, where I work, and our breast cancer screening rates are far far better than the study quoted at the San Antonio Breast Symposium, any death that was too soon and preventable in my mind is a failure.  A failure not of the individual patient, but of the healthcare system.

Perhaps that is why she was a health care activist.

Although I've never met her, I am certain that given a choice had she had the healthcare system around her which optimized her chances for the right decision, she would have never wanted to leave her children at such a young age.  The absence of such a system is the true tragedy.

My thoughts are with her family, friends, and most especially her children, Cate, Emma Claire, and Jack.

Thursday, November 18, 2010

Why Doctors Need To Be Less Like Chuck Yeager and More Like Captain Sullenberger

A recent medical error of a wrong site surgery that occurred in one of the country's best hospitals, Massachusetts General, reminded me why doctors need to be less like Chuck Yeager and more like Captain Sullenberger.  Growing up I always wanted to be a fighter pilot, years before the movie Top Gun became a part of the American lexicon.  My hero was World War II pilot Chuck Yeager, who later became one of the country's premier test pilots flying experimental jet and rocket propelled planes in a time when they were dangerous, unpredictable, and unreliable.  Much like the astronauts in the movie, the Right Stuff, Yeager and his colleagues literally flew by the seat of their pants, made it up as they went along, and never really knew if their maiden flight in a new aircraft might be their last.  They were cowboys in the sky wrangling and taming the heavens.

Fast forward to January 2009, when shortly after takeoff a one in a million chance, a double bird strike completely disabled a US Airways jetliner.  Captain Chesley Sullenberger with the help of his co-pilot Jeff Skiles ditch the aircraft in the Hudson River in under four minutes even as the nation surely expected a tragedy.  But not on that day.  Not with that pilot.  Though Sullenberger, an already accomplished pilot from being the top cadet at the US Air Force Academy, an aviation safety expert with his experience as a crash site investigator for both the military and civilian sector as well as an instructor for US Airways pilots, he credited much of the success to his training and his experience.  Sullenberger had studied why pilots and crews often failed in critical emergency situations.  He also mastered and understood the physics and performance aspects of the aircraft he flies (his wife calls him a pilot's pilot).  He also believes strongly and instinctively the need to follow checklists and protocols to ensure the right thing is done every time.  This was drilled in him in the military where the difference between life and death in a fighter plane could be simply a matter of feet and seconds.

Though the media dubbed the landing as the "Miracle of the Hudson" and named him America's hero, Sullenberger modestly noted he was simply doing his job, which only endeared him even more to a country looking for positive stories in a time of a new president, an unprecedented financial crisis, two wars, and an uncertain future.  Ask Captain Sullenberger, review the cockpit recordings, and you'll discover that he wasn't really flying by the seat of his pants but was very methodical, rational, and logical as he quickly evaluated his three options: return the plane back to LaGuardia, go to Teterboro, New Jersey, or ditch in the Hudson River.  While planning for a landing after the unthinkable, his co-pilot automatically did his job attempting an engine restart by cycling through the checklist seven times.  They landed the plane successfully with a little luck, a lot of skill, and a full understanding of how humans make mistakes in particularly stressful times and what mechanisms when put into place, checklists, protocols, and training, can decrease these to a minimum.  Frankly, no one else could have landed that plane except Sullenberger.

Which brings me back to the medical error noted in the New England Journal of Medicine.  Dr. David Ring, after a day of many carpal tunnel surgery releases erroneously performed the surgery on a woman who was supposed to get a trigger finger release.  Though he has been praised by many to be courageous to publicly acknowledge the error, what was quite disturbing was his one comment:

"I no longer see these protocols as a burden. That is the lesson."

His insightful comment should not be seen as an anomaly.  Dr. Ring should also not be ostracized.  He speaks the truth.  Doctors today still see themselves as cowboys, the heroic individual who despite whatever obstacle or hardship can just get the job done.  Somehow, we are too smart to rely on surgical timeouts, checklists and protocols.  Instead, we refer to the entire process "cookbook" medicine and go through the motions just to appease regulators and administrators.

It is this arrogance and hubris that pervades our profession that is quite disturbing and equally disappointing.  A March 2010 report found that medical schools are not doing enough to prepare future doctors on how to develop the mindset for patient safety.  Yet for much of medicine, we understand the precisely the science of how to do things better.  No central line infections occur when all doctors abide by a simple 5 point checklist developed by John Hopkins intensivist Peter Pronovost.  Merely having every surgical team member introduce himself before surgery as noted by New Yorker writer and general surgeon Atul Gawande improves communications so that the team is more likely to function better in times of crisis.  Even a singular phone call by Dr. Gawande to the blood bank to hold blood on standby for a "routine" surgical procedure, which he had done many times before and never needed the blood, ended up being critically important.  On that day with that routine surgery, his patient had a tear which required 30 units of blood.  If Dr. Gawande hasn't called for blood on standby before the operation started, his patient would have died.

We know much more about medicine since the development of antibiotics, antiseptics, and best practices, yet we act no differently than 150 years ago.

"In 1852, the Massachusetts General Hospital was featured in a New York Times article detailing a series of events that led to the death of a young patient. Under the care of the surgeon, Dr. John Collins Warren, the patient had received chloroform instead of the usual chloric ether anesthesia. The event that we describe here, more than 150 years later, is a sad reminder that despite expert and well-intentioned providers, our patients continue to face risks caused by human fallibility and systems that do not fully support our efforts to provide safe care."

It's time doctors stopped acting like the cowboy test pilots of Chuck Yeager's era and adopted the mindset of Captain Chesley Sullenberger and doctors Pronovost and Gawande.  Protocols and checklist exist for the safety of our patients and to ensure highly reliable outcomes everytime.  Until doctors all adopt this mindset, medical errors will continue to happen despite policies and regulations because somehow our profession still believes we are infallable.

Thursday, November 11, 2010

Why Doctors Talking to Patients is Better than Technology and Blood Work

The Associated Press ran a provocatively titled piece recently, "Family health history: 'best kept secret' in care", which noted how a geneticist at the Cleveland Clinic discovered that asking about family members and their history of breast, colon, or prostate cancer was better than simply doing genetic blood testing.

Surprising?  Hardly.  This is what all medical students are taught.  Talk to the patient.  Get a detailed history and physical.  Lab work and imaging studies are merely tools that can help support or refute a diagnosis.  They provide a piece of the puzzle, but always must be considered in the full context of a patient.  They alone do not provide the truth. 

A tool to help organize the family history can be found at the US Surgeon General's website.

The challenge is being able to have a candid conversation with a doctor as office visits seem to be shorter.  Filling out this simple one page "patient resume" may help.  Give it to your doctor, particularly if she is new to you, especially when having a general check-up.  That is a good time to have a robust discussion about what you must do to stay healthy and well.

Why is this important?  First year medical students often ask me how do they know what parts of taking a patient's history, a person's past medical history, surgical history, family history, and social history (smoking, alcohol, drug habits) can be safely skipped or ignored.  In other words, already early in their careers they want to hone down, eliminate unnecessary time and unneeded questioning to clinch the diagnosis.  They want to be good doctors.

They quickly discover that good doctors can't know a patient's problems or symptoms without understanding the whole story.  Good doctors get the complete story to get the best answer.  Trying to piece a problem together by ordering tests, blood work, or xrays won't get to the truth, even though we still fool ourselves into thinking they can.  As this news article demonstrates despite all of the advances in technology, there is still value and power in simply talking and listening to patients thoughtfully.

Saturday, November 6, 2010

Book Review - the Empowered Patient by CNN Elizabeth Cohen. Too Adversarial.

I understand the frustration and anger in CNN Senior Medical Correspondent Elizabeth Cohen’s new book, the Empowered Patient.  I agree that all of the horrible patient stories should have never occurred.  As a practicing primary care doctor who has witnessed near misses and bad medical outcomes affect family members, I too wrote a book encouraging patients to be informed and engaged about their care.

The problem is that the Empowered Patient is too adversarial.  If anything, it is biased, which is completely understandable given the failings of the healthcare system, and is not balanced.  If she had wanted a book that helped patients be informed, engaged, and a true partner in health, she falls far short.  Those of us working to make the healthcare system safer and more patient focused will find ourselves on the defensive as soon as we walk through the door if patients follow everything she says.

Chapter titles include How to Be a “Bad Patient” and How to Find Dr. Right (and Fire Dr. Wrong).  She reminds readers that “your relationship with your doctor is a business relationship… You pay her, and she takes care of your medical problems.  End of story.”  Readers should consider firing their doctor if they “repeatedly have to spend inordinate amounts of time in the waiting room (more than fifteen minutes or so)”.  Yet, she hopes readers can find Dr. Right, someone who is an excellent communicator and someone you can trust and feel good about.

Through her stories in How to Get Good Drugs Cheap and Don’t Fall for Medical Marketing, Cohen implies that all doctors are influenced by drug reps, on the payroll of pharmaceutical companies, and only write expensive brand name medications.  She completely ignores how direct to consumer advertising cause patients to demand these “me too” drugs.  She doesn’t highlight the studies that show doctors when faced with this situation, though ambivalent, often acquiesce.  Cohen suggests that readers ask their doctors if they have “any financial ties to a drug or device company”.

In the section How to Avoid a Misdiagnosis, she illustrates two patients who could have died because doctors were about to begin chemotherapy and radiation treatments based on erroneous diagnoses.  Using the internet, it was clearly apparent to the patients that the rare condition they supposedly had didn’t apply to them.  They didn’t fit the typical patient description for the illness.  The doctors’ failings were that they relied too heavily on the pathology reports. They should have looked at the complete picture and the pathology report in the context of the patient.  Instead, they anchored their decision solely on the pathology report.

Again, Cohen is completely silent about the patient aspect.  The same anchoring phenomenon can and has been occurring with patients.  Increasingly far more patients are focused on what the test showed, whether blood work or CT scans and MRIs, instead of what makes sense based on a patient’s history and examination.  Patients are also avoiding office visits relying instead on technology to provide answers when these are simply tools and not necessarily the truth.  Imagine the erroneous conclusions that might occur.

Armed with her information it is impossible to see if it is possible for anyone to find a Dr. Right or a time when patients can focus on getting better instead of being very vigilant at every point of care to the level of paranoia.  Perhaps that wasn’t her intent, but as a doctor on the frontline it is hard to see any other interpretation.

Though Cohen rightly notes that 99,000 Americans die annually from hospitalized infections and that 98,000 die from medical errors in the hospitals, she also ignored that 100,000 deaths could be averted if simple important interventions occurred.  Patients with hypertension had their blood pressure controlled.  Patients with heart disease had their cholesterol controlled.  Women at age 40 begin screening for breast cancer.  Both men and women at age 50 get screened for colon cancer.  Surely these are equally as important issues for empowered patients?

There were a few of sections that were worthwhile – How to Become an Internet MD, gives excellent and thoughtful advice on how patients can use the internet, Don’t Let a Hospital Kill You, and You vs. the Insurance Industry.

If there was any silver lining in her book, then it is as doctors working in an incredibly complex system comparable to environments associated with airline pilots, military aviators, and astronauts, we must do much better.  Saying medicine is different is not acceptable.  We need to adopt highly reliable systems, systematically improve training to minimize inherent unconscious bias, and a serious dose of humility in understanding that patients concerns are legitimate and must be addressed. 

Though her CNN colleague, Dr. Sanjay Gupta says this is “a book no household should be without”, I can safely say there are other books that can provide you the skills and knowledge to engage and partner with your doctor better than this one.

Sunday, October 31, 2010

The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

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It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

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The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

Friday, October 15, 2010

Abraham Verghese - The Top Gun of American Medicine

The first year medical students I precept were too young to see Tom Cruise's alter ego Lieutenant Pete "Maverick" Mitchell grace the big screen in the 1986 blockbuster film Top Gun.  Yet, the story has a relevant analogy to medicine. 

According to the film, during the Vietnam war American pilots were relying too much on technology to bring enemy fighters down.  They weren't as skilled in taking out the opposition.  They fired their technologically advanced missiles to try and get the job done.  They didn't think.  It didn't work.  They forgot the art of dogfighting.

The military discovered that technology alone wasn't going to get the job done. The best fighter pilots needed the skills, insight, and wisdom on when to use technology and when not to. As a result, the Navy Fighter Weapons School, known simply as Top Gun, was created to retrain the military pilots on this vital lost skill. 

The goal of the program was specifically to make the best of the best even better.

Like the military, the country is discovering that the healthcare system enabled with dazzling technology isn't getting the job done either.  One study suggests that Americans don't live as long as citizens from other industrialized countries not due to our obesity or smoking habits but because of the failings of the healthcare system even though we pay more per capita on healthcare.  Since the recent and current generation of doctors, residents, and medical students are trained to rely heavily on technology, the situation is only going to get worse.  These doctors do not know how to do a thoughtful history or thorough physical examination.  Individual patients as well as the nation will pay a price for more unnecessary testing as well as wasted time and money which could have been avoided if doctors focused on the art of medicine. 

To slow healthcare costs, the next generation of doctors will need the skills, insight, and wisdom on how to take an accurate history, perform a thoughtful clinical examination, and use technology judiciously.  They must be experts in the art of medicine.  Like the art of dogfighting, the art of medicine was a skill that should have been embraced as technology proliferated instead of being marginalized in training.


So who are medicine's Top Guns?  Who are the best of the best?  Where is medicine's Navy Fighter Weapons School?

If medical students want to be the best of the best, then they should look no further than Dr. Abraham Verghese of Stanford Medical School.  Dr. Verghese, already an accomplished author who is also board certified in internal medicine and infectious disease, engages them with the virtuoso performances on the fine art of medicine.  For doctors to become expert diagnosticians, he and his colleagues outlined 25 skills doctors should know simply as a beginning to more learning.

If students want to be in the specialty where the best and brightest work, then they should look no further than primary care, family medicine or internal medicine.  Besides dermatology, primary care is a specialty where doctors often start evaluating patients by talking, observing and examining.  Primary care doctors often see patients for the first time without any test results as these visits are usually the first time someone has sought medical care.  As a result, they need to skills to figure out which patient needs more extensive work-up and which one can safely care for the problem at home.  Though primary care isn't as attractive to medical students and proposals are underway to make the field more appealing, there is no question that it is the most cognitive specialty - a doctor's doctor specialty.

If the US healthcare system is to provide Americans better care it will need a generation of Top Guns in primary care to lead the change.  What Dr. Verghese offers his medical students and residents in his training is what all of us want in our doctor - someone who listens, observes, and examines thoughtfully to get the right diagnosis.

In other words, a doctor who is the best of the best.  As a practicing doctor, I would jump at the opportunity to learn from him.

Friday, October 8, 2010

How to Pick Good Health Insurance - Your Life Depends on It.

Unless your doctor is a policy expert, in healthcare administration, a researcher, an author or blogger, I seriously doubt he will be reviewing an important report card that helps you pick the best health insurance plan that keeps you healthy.  Published annually by the National Committee for Quality Assurance (NCQA), this year's report card ranks 227 health plans across the country on their ability to keep you healthy and well, treat you quickly, and how patients feel about their insurance coverage.

Because unlike banking or airlines where there is not much difference in ATM machines or planes, there is a big difference in whether a health insurance plan helps in keeping its enrollees healthy.  Do children get their vaccinations?  Do healthy mothers get screened for breast cancer or cervical cancer with mammograms and pap smears respectively?  Do kids only get antibiotics appropriately for strep throat and not overtreated and unnecessarily when they have a viral illness or cold?  Are adults over 50 screened for colon cancer (something Dr. Oz can relate to).

You are incredibly busy living life.  Your health plan should proactively works with you and remind you to do the right thing?  It also helps doctors do the right thing.   

The NCQA report has been part of the US News and World Report best health plans over the past few years and will now be incorporated as part of Consumer Reports.

Be smart.  Be wise this year.  Trying to pick a health insurance plan seems easy.  They are all the same, right?  Simply look at the price.

No.

This is different.

This isn't auto insurance.  This is your health.  You want the best.  Choose wisely because your life and those of your family depend on it.

Monday, October 4, 2010

Friday, October 1, 2010

Do I Need Cholesterol Medication? Is My Cholesterol High? The Simple Truth.

The New York Times recently ran a piece that wondered if doctors were treating patients with cholesterol lowering medication unnecessarily because a web-based calculator over estimated a person's risk.  The program was proudly sponsored by the pharmaceutical roundtable and was available at the American Heart Association.

The implication was obvious. Simple tool determines an individual's risk for heart attack or death from heart attack.  It over estimates risk.  Patients treated unnecessarily.  To be also clear, the program did underestimate risk as well.


Unfortunately, the article missed an important point.  While the simplified calculator may not be as accurate as the more complex algorithm used by the National Cholesterol Education Program, the truth is doctors are likely to be overtreating patients not because the former program is presented by the pharmaceutical roundtable, but for another reason.

In my experience, doctors don't use any web-based tool.  Instead they use a simple rule - is the cholesterol over 200, which is even less precise than the vilified web calculator.

This is rather disappointing, yet occurs too often.

The public has been told erroneously that if your cholesterol is over 200 that it is bad.  Understandably to generate public awareness, a simple number is far easier to act on than the messier nuances determined by the Framingham heart study.  This classic and famous study found that total cholesterol and HDL (good) cholesterol, the age, gender, smoking status, blood pressure, and whether a person is taking blood pressure medication could provide an estimate of an individuals chance of having a heart attack or dying of one over the next 10 years.  In other words, it isn't just the cholesterol in isolation that predicts heart disease, but the profile of the whole person that does.


As a result of these calculations, some basic guidelines appeared.  Patient with a risk of greater than 20% over the next 10 years should be on cholesterol lowering medications like the "statins". Those with a risk of 10% or less should simply work on dietary changes, maintaining a healthy weight, and exercise.  Those between 10 and 20% should also adopt lifestyle changes and consider cholesterol lowering medication.

The decision tree is now far more sophisticated than simply treating a total cholesterol of over 200 with medication.

So when patients join my practice, particularly those who do not have high blood pressure, diabetes, or a history of heart disease, and who are on medication to lower cholesterol, I do this calculation with them.  Shockingly, many don't need medication. The only exception is patients with diabetes or heart disease where cholesterol lowering medication is a must. 


Though these patients are pleased, they are also somewhat reluctant.  Everyone else they know is on cholesterol lowering medication.  Bucking peer pressure, even when scientifically grounded, can be incredibly difficult.  It goes to show how powerful and effective the public service announcements have been to generate awareness.  It also shows how difficult it is to fight a perception, even when it is wrong, particularly when other doctors for expedience sake give patients what they think they want rather than what they need.  (Ever gotten antibiotics for a cold or viral illness instead of reassurance and TLC?)


So if your doctor tells you that you need cholesterol lowering medication, ask him how he reached that conclusion.  He might be doing a simple mental shortcut rather than taking a few minutes to determine your risk.  Ask him if he can quantify your risk over the next 10 years.  If you hasn't an idea what you are talking about,then ask him to Google "10 year risk calculator" to find the right test.

If you don't have diabetes or a history of heart disease and you do discover with a calculation that cholesterol lowering medication is prudent, the good news is there are a few excellent generic medications available to do the job.


Just don't ask for Lipitor the most widely prescribed cholesterol lowering medication.  It's very powerful yet most people don't need that level of potency to protect themselves from heart attack.  It's expensive as it isn't generic yet (Lipitor aka ATORVASTATIN went generic in 2012).  You probably will do just fine with the generic version of Zocor, simvastatin.  Don't take my word for it; that is the conclusion by medical experts for Consumer Reports.  If you are already on cholesterol lowering medication, don't stop until you check with your doctor to make sure it is safe to do so.


Remember, it isn't what you think you want; it's what you need.  Marketing of Lipitor or public service announcements about cholesterol can shape what you think you want.  Talking candidly with your doctor may actually help you determine what you need. Not only might this save you money, but also prevent you from being unnecessarily overtreated.

Wednesday, September 22, 2010

Does the Flu Vaccine for 2010 - 2011 Contain the Swine Flu Vaccine? Should you get a flu shot?

It's that time of year again.  Children back at school.  Football season is underway and baseball playoffs to start soon.  The television networks are rolling out their new shows.

And it is also time to think about getting flu shots.  Just got mine today as I have done annually since going to medical school.

Compared to last year, there isn't as much news about the flu or the flu vaccine. 

This year the Centers for Disease Control (CDC) gives clear guidelines that everyone aged 6 months and older should get the influenza vaccine. 

This month the American Academy of Pediatric recommends that all healthcare providers should be required to get the influenza vaccine.

And one fact that hasn't gotten much attention is whether the 2009 H1N1 virus is included in the 2010 - 2011 vaccine?

Yes it is.  This year's vaccine will be as safe as vaccines in past years as the production process is unchanged.  Inclusion of the 2009 H1N1 virus will not be a problem.

These facts are far calmer than the news in the spring of 2009 when the appearance of a novel influenza virus had the world extremely anxious.  Unlike other flu viruses, the swine flu or H1N1 virus was more easily contracted by young and healthy adults as well as infants, children, and pregnant women.  Older adults seemed to be spared.  A flu virus attacking young and healthy resulting in deaths raised concerns that perhaps this was the beginning of a pandemic much like the 1918 influenza pandemic which killed millions worldwide.  Influenza or flu is not simply a bad cold.  It's a viral illness that nationally causes tens of thousands of deaths.

When first signs of this new virus appeared in April 2009, scientists worked feverishly not only to identify it but also figure out how to create a vaccine to protect the public.  The potential for millions of deaths worldwide was a significant possibility.  By the fall, a new vaccine was available.  Because of the time it took to determine the viral DNA sequence, it was not included in the 2009 - 2010 flu vaccine combination batch.  Patients would need to get a separate flu shot in addition to the traditional one.  

That is when the firestorm of controversy occurred.  Instead of being grateful that scientists that a new vaccine was produced in record time, concerns of about safety appeared.  In addition on the initial rollout, there was inadequate or uneven supply of vaccine which resulted in lines of people waiting for a limited supply of vaccine.  People were being turned away.  To add to the uncertainty, the optimum dosage of vaccine to be given to children wasn't initially clear.  All of this didn't help allay fears.  "Deadly virus about to kill millions.  Untested vaccine rushed to production."

None of these stories panned out.  Fortunately the H1N1 pandemic wasn't as deadly as initially feared.


Nevertheless many of these unconfirmed concerns spread quickly and were repeated resulting in many unnecessarily scared patients.  People are increasingly skeptical of large institutions and organizations, even if they are working in the public's best interest.  As people become more irrational about making important decisions of significant consequence, it is vital that people can trust a group of individuals who put the well-being of others first.  It is vital that doctors step up and lead by example.

Doing the right thing means that if controversy appears, whether regarding vaccinations or healthcare reform and policy changes, doctors must step up and be heard.  Too much misinformation exists.  The public is increasingly confused.  Speaking up means sometime you have to disagree with fellow doctors.

Doing the right thing sometimes is the hardest thing to do.  Getting a flu vaccine certainly isn't one of them.  Do the right thing, roll-up your sleeves, and get the flu vaccine.  It's what I'll be doing for my family.  Demonstrate to your staff and your patients it is the right thing to do.

Doctor, get vaccinated.  Remind them to get the flu vaccine.

Thursday, September 16, 2010

Empowered Patient - Is This What Americans Really Want? Probably Not.

Empowered patient.  Consumer driven healthcare.  Transparency.  Access to their full medical records online.  Review the latest news and you'll discover more books and articles recommending patients be advocates for themselves.  The pitch?  The only way to get the best care is to be thorough, informed, and always asking questions. This perspective is understandable because advocates have observed a healthcare system that provides inconsistent quality, too many preventable medical errors, and overtreatment resulting in unnecessary injuries and deaths.  Even I've written a book saying the same thing and I hate to write. 

The public is urged to take charge of their health and their healthcare.  When they have a problem, ask the doctor questions.  Do research.  If they need a procedure, shop around to get the best deal.  Adopt good habits.  Eat more fruits and vegetables.  Stop smoking.  Maintain a healthy weight.  Exercise regularly.  These will improve health and be less costly in the long run.  


But is this what Americans really want?  Do they want to be empowered patients?  Can they be empowered patients? 

Frankly, no.

Americans don't want to be empowered patients anymore than they wish to be experts in retirement planning or IT gurus.  Life is already too busy.  Both parents are working, sometimes two jobs to make ends meet.  Children's schedules are packed with so many activities that simply having playtime to be a child is almost seen as being lazy (even though it might be the right thing to do).  People know they should exercise, lose weight, and eat fruits and vegetables.

But the problem is in adopting both healthy habits and having patients shift their behavior to be more engaged in healthcare is that it is more than the result of poor individual choices or lack of knowledge.  People are not particularly rational even when it is in their best interest and even when it makes economic sense.  In fact, it is incredibly hard to make those right choices unless the system is tweaked to promote the right behavior.  Shifting the system requiring patients to have more financial responsibility in medical care through higher deductibles and copays won't do it.  History has already shown how this failed in retirement planning.

In the 1970s when employers started shifting from pension plans (defined benefit) to 401(k) plans (defined contribution) for cost reasons, the theory was employees would do better in retirement planning.  No one would have more incentive than the individual employee to thoughtfully research and invest their money for retirement than the person directly benefiting from it.  Employees would deduct money from their paychecks, determine an appropriate asset allocation and rebalance their funds to maintain a risk level they were comfortable with.  It was thought to be a win-win.

Decades later, however, it became clear what people should have done and what they were actually doing was vastly different.  Observed behaviors were not consistent with academic theory.  Too many people didn't participate in their retirement plan.  Those who did often had funds in a money market plan which never kept up with inflation and cost of living increases.  Others didn't diversify at all putting their dollars at high risk for failure.  These discoveries led to the rise of behavioral economics which began asking the right question - why don't people do what is in their best interest?

It's because we aren't as rational as we think we are.

As a result, over the past few years employers and the financial services companies having been changing retirement planning to nudge employees to make the right decision.  Employees are now automatically enrolled into a 401(k) plan and no longer need to sign up.  A small portion is deducted from their salaries automatically.  The dollars are invested in target date funds.  Target date funds invest money among a variety of assets to promote diversification to mitigate risk.  More importantly, the funds are shifted automatically over time to more conservative assets as the employee gets closer to retirement, the financially prudent thing to do.  The rate of return typically is higher than the money market accounts and ahead of inflation.

As a result of these changes the number of people not participating in 401(k)s fell from 25 percent down to 5 to 10 percent.  More importantly, they are invested correctly for their retirement.  It is what they would have chosen to do anyway.  If they had time or the desire to do so.

For the minority of individuals who were far more motivated, these programs did not hamper them to invest as they saw fit.

This is a true win-win.

Yet in healthcare, the same troubling trends are occurring again.  The risk of making the wrong choice is much higher as are the consequences.

Much like pension plans decades ago, healthcare costs for companies are increasingly a larger financial burden.  As a result, more insurance premiums are being shifted to employees with increasing copays and now deductibles.  The theory goes if patients have more responsibility for their care that they will make the right choices to stay healthy and well.  Because they have more financial responsibility, they will be more thoughtful when they need to see a doctor and if testing is required they will ask questions, shop around, and do research.  After all, it's their life and their money.  Who else would be most vested in making the right decision than the patient?  It would be a win-win.

Sound familiar?

Familiar and flawed.  It's about improving the system and not relying on individuals to be heroic to do the right thing.

A recent USA Today article about the decline death rate from motor vehicle accidents reminded me of how powerful improving the system is in nudging the right behavior.  It also reminded me how experts continue to wrongly attribute either success or failure to the individual.

The number of people killed from traffic accidents in 2009 was the lowest in 60 years despite the fact that
in 1950 there were about 45 million cars for 150 million people while today's numbers are 256 million cars for a population of 310 million.

NHTSA Administrator David Strickland contributes the drop in fatalities to increased seat belt usage and a strong anti-drunken driving campaign nationwide.
Both of which are individual behaviors.  Now Mr. Strickland may be talking about the year to year decrease in fatalities.  He doesn't address or acknowledge the system improvements that have allowed six times as many vehicles on the road with a population that has doubled in size.  There is no mention of better highway design and signage, rumble strips, crash zones in front of highway off-ramps, guardrails, red traffic light cameras, safer cars with airbags, anti-lock brakes, and better engineering with crumple zones and stronger passenger cages to protect occupants as reasons for a death rate that is the best in sixty years.

Perhaps understanding the importance of system to help the individual, this blurb from the article shouldn't be surprising:
More people die from car crashes in rural areas, with urban areas a distant second, according to NHTSA's data. Driving off the road is the largest type of fatal accident. That's followed by accidents at intersections.

It's not just about individuals making right choices but about the system enabling them to get there.  Rural areas probably don't have sophisticated road design or some of the above system improvements.  Driving off road causing a large number of fatalities makes sense.  In that situation, it really is simply the individual and the car against the wilderness.

So it isn't I'm against the empowered patient movement.  I wrote a book giving them the same tools many others have.

It's a fundamentally different view of the world.  Does enabling good health and providing the right care at the right time boil down to either asking the individual to make the right choices or making the system to enable her to easily get to the right choice?

The former won't work.  With my colleagues, I'm working very hard on the latter.

Friday, September 10, 2010

Tom Brady Car Accident - Driving Safe Car Saves Lives and Careers.

New England Patriots NFL quarterback Tom Brady was on his way to practice when he crashed into a minivan which allegedly ran a red light.  His Audi S8 car T-boned the other vehicle a few blocks from his home.  A relieved New England Patriots owner Bob Kraft noted after the accident:

"[Tom] arched and prepared himself and we're just lucky with the glass and angles. We have a lot to be thankful for. It was really a miracle....We're very, very lucky. Patriot Nation is lucky he had his seatbelt on."

Was it simply luck or good car design and mechanical engineering?  Crumple zones and the passenger cage of a car when built for maximum safety decrease injury.  Yet, unfortunately, there is significant variability among safety in cars.  Brady walked  away from the accident for a variety of reasons.  As a future hall of fame quarterback, Brady has lightning fast reflexes when analyzing defensive blitzes and options when throwing the football.  Quickly bracing himself for impact may have helped.  Wearing a seatbelt definitely helped.

What also helped the most was the type of car he drove.  Audi cars were recently recognized by the Insurance Institute of Highway Safety as Top Safety Picks with the manufacturer recognized with more models than any other luxury German car brand. Earning a Top Safety Pick requires that the vehicle receive a good rating in each of these categories - high-speed front and side crash tests, a rollover test, and protection against neck injuries after rear impact with evaluations of seat/head restraints.  Perhaps had celebrity Dr. Frank Ryan driven a top safety pick car despite his vehicle's rollover, he might be alive today.  There is tremendous variability in a vehicle's ability to protect its occupants which vary among manufacturers as well as models and model year.

Driving a safe vehicle should be as important as exercising regularly, eating healthy, and maintaining a good weight.  Much like quitting smoking or losing weight, the goal is to prevent premature death or disability.  Unintentional injuries are the leading cause of death for those under the age of 34 and the third leading cause of death for people between ages 45 to 54.  Motor vehicle accidents account for the majority of unintentional injuries.  In that moment, all of those healthy habits become meaningless, even for a superstar athlete.  You can do everything right, like Dr. Oz, and discover that you still can have a precancerous colon polyp.


Life happens.  Simply bad luck?  Perhaps.  What can you do to mitigate the risk or bad luck further?

Plan for it the best you can.  In this case, having a car brand that is among the safest in the world, helps.  His car saved his life and saved his career.  It protected him from needing an emergency room visit and evaluation.  As a result, Brady simply walked away from the accident.  He made his practice a little while later and finished his drills with teammates.  He displayed no sign of injury or diability.

Was all of that worth the time and effort to find a car that is fun to drive and yet incredibly safe?

You bet.  Don't believe me?

Ask his wife, Gisele Bundchen, and his sons Benjamin and John.  I'm sure they are glad to have him home safe and sound even as he takes his hits on Sunday as the premier quarterback in the NFL.

Tuesday, September 7, 2010

Dr. Oz, Colon Cancer Screening, Colon Polyp, and Colonoscopy - What Can We Learn

I'm a big fan of Dr. Oz. What is there not to like about the guy?  He's incredibly smart, a graduate of my alma mater, the Wharton School, energetic, pretty good looking, and charismatic.  Though as a doctor I don't always agree with him, as I practicing primary care doctor I have great respect for his mission of getting all Americans healthier. (I wished he could have given me a testimonial for my book, though he sent a nice email wishing me luck. Perhaps my next book?). Though I have a busy day job, the season premier for his second season was one I could not miss. He turned fifty in June and had a colonoscopy in August to screen for colon cancer.  As a result he saved his own life.

Dr. Oz had a colon polyp.  The polyp which was removed was found at the distal sigmoid and identified as an adenomatous polyp.  These types of polyps have the potential to become cancerous over time.  Had it been left in the colon undetected, it could have become cancerous over a period of years.  Had he had delayed his colonoscopy until age 60 it could have developed into a full blown cancer.  Like most of us, Dr. Oz admitted that life is busy and we often delay important screening tests because we don't have time.  Fortunately, the polyp was removed and the likelihood of developing cancer from that growth is essentially zero.  Nevertheless to make sure, he will be repeating a colonoscopy again in a few months.

Understandably, Dr. Oz was shocked and humbled by the experience and the colonoscopy finding.  No one likes to be a patient, particularly cardiothoracic surgeons, who are often in complete control.  Like many patients and particularly even more doctors, he had a bit of arrogance going into the procedure because he works hard on staying healthy.  The colon cancer screening test was simply a thing to check off on his to do list.  A formality, but nothing that was taken seriously.

Instead, the procedure saved his life.  As a result, instead of leading in the second season with a ratings favorite of weight loss, the doctor in Dr. Oz did the right thing.  He aborted the original premier of weight loss originally scheduled because of the surprising colonoscopy findings and refocused the premier on the nitty gritty about hunting down the second leading cause of cancer deaths and filmed his most personal show ever.

He argues, rightly, that we must make time to do the right things.  Had he not been the host of his show, he would have been inclined to do procrastinate as he is a "sloppy patient"".  "Lifestyle is not the cure all by itself."  Part of being healthy and staying healthy is getting screened for cancer, high blood pressure, high cholesterol, and diabetes.

Dr. Oz had no symptoms, no family history of colon polyps or colon cancer.  What is particularly heart wrenching is that thirty-two thousand Americans died of colon cancer because they were never screened.  When caught early, colon cancer is highly curable.

According to Dr. Oz's expert, the majority of patients with colon polyps have no symptoms.  In other words, a deadly time bomb could develop and you wouldn't even know it unless you looked.  Even more disturbing is that seventy percent of patients with colon cancer have no family history.

Although Dr. Oz recommended that all Americans age 50 years and older be screened for colon cancer with a colonoscopy, his polyp was discovered at the distal sigmoid which would have been easily reached with a sigmoidoscopy.  Other options for colon cancer screening also include a virtual colonoscopy, stool testing, stool DNA testing, or barium enema, which are all recommended by the American Cancer Society.

My personal belief is out of all the options to screen for colon cancer, starting at age 50 all Americans who are otherwise healthy and have no family history of colon cancer or polyps should opt either for annual stool testing with a sigmoidscopy every five years or colonoscopy every 10 years. There is nothing magical or superior about a colonoscopy per se as it can also miss colon cancers or polyps as well. Research finds them equally as effective.

The biggest obstacle to preventing colon cancer deaths is that Americans simply don't want to be screened. Colon cancer screening is something I've been passionate about since residency training, when I learned one of my colleague's father died at a young age because of it. Getting my patients to want to have an invasive procedure like a sigmoidoscopy or colonoscopy is incredibly hard.  Yet, I have my 30 second elevator speech nailed.  With Dr. Oz's public campaign, I can refine it even further to this:

If Dr. Oz, arguably a very healthy individual, had a colon polyp, why can't you?

As doctors we need to lead by example. Thanks Dr. Oz for doing the right thing!

Tuesday, August 31, 2010

The Truth and Facts about Concierge or Boutique Medicine

A recent piece in the New York Times wondered if the few patients who can afford to pay for additional attention and access to their primary care doctors in a concierge medicine or boutique medicine practice might be ethical since the extra dollars are used to support the traditional primary care practice that the vast majority of patients currently receive. 

Questions you might ask are:

What is a concierge medicine or boutique medicine practice?
Is it worth the money?
Is the care better quality?
Is it possible to get similar access and care by doctors not in a concierge or boutique medicine practice?



When you think of a concierge, you think about a fancy hotel staff person who answers questions, speaks various languages; and books reservations to restaurants, events, and tours, even sold-out attractions — right? The hotel concierge is your insider, someone who possesses intimate knowledge of the city and recommends must-see sites like a true local. You are personally cared for and pampered.

Imagine, then, your physician providing the same attentive service. Indeed, a small and growing number of physicians are offering this concierge care, also known as boutique or retainer medicine. Physicians provide services typically not covered by their traditional health insurance, like annual comprehensive physicals and direct access to their doctors twenty-four hours a day via home phones, cell phones, and pagers. Other benefits include same day appointments with longer physician face time, little to no waiting time in the lobby, and a focus on preventive care. In some practices, the physician will even accompany a patient to specialty doctor appointments and perform house calls. Sound pretty nice? But beware: this kind of service comes
at a price. Patients in boutique or concierge care pay a retainer ranging anywhere from a few hundred to a few thousand dollars per year.

The concept of boutique care may have started in 1996, when the Seattle Supersonics former team physician wanted to make available to the general public the same level of medical care and attention provided to professional athletes. MD2, the company he founded, provided a spa-like experience to a select few patients who could afford the $10,000 to $20,000 annual retainer fee (in addition to insurance premiums and
costs).

Many physicians are attracted to this new physician-patient relationship as they become more disenchanted with large patient panel sizes, lower reimbursement rates, shorter office visits, increasing overhead, malpractice costs, and paperwork. They want to slow down and spend more time with patients, which is difficult in the current climate of falling insurance reimbursement.

In the July 2002 issue of The Journal of Family Practice, one study noted that 27 percent of physicians anticipated a moderate to definite likelihood of leaving their practices within two years. Leland Kaiser, Ph.D., a healthcare futurist, also notes that lack of physician accessibility and availability is also causing consumer discontent and is a driving force toward concierge medicine.

The high retainer fees these physicians charge frees them financially from health insurance contracts and allow them to care for a much smaller patient panel (typically a third or less than an average physician’s panel of two to three thousand patients). Perhaps not surprisingly, these practices attract patients who are upper middle class, middle-aged entrepreneurs, and wealthy seniors.

Supporters of concierge care claim it’s a lot like private school education. Parents who wish to supplement their children’s education can send them to private school, paying extra for a potentially more personalized education that offers more choices (at a cost). “Like education, luxury primary care is simply a response to a market need [that] serves the interests of both the consumers (patients) and suppliers (physicians).” As long as there are people willing to pay extra for additional personalized care, the more likely the boutique medicine trend will continue.

Understandably, not everyone is happy about this new trend. While the American Medical Association (AMA) has not found concierge practices to be inconsistent with the goal of healthcare delivery, it bears repeating that a physician’s duty is first and foremost to his patients. So, as in the case with physicians who retire or leave a practice, doctors planning on changing to or adopting a new concierge practice need to help their former patients transition to other healthcare providers. If no other physicians in the community are able to care for these patients, the AMA notes that the original physician may be ethically obligated to
continue care.

State and federal healthcare agencies, as well as insurance companies, are watching the new developments carefully to ensure that physicians practicing boutique medicine do not require retainers to provide services already covered by a patient’s health insurance. In July 2003, the government took action and fined a physician over $50,000 after he charged his patients $600 for services partially covered by Medicare.  In 2004, the Health and Human Services Federal Agency reiterated the long-standing policy that physicians are not allowed to charge Medicare patients additional fees for services already covered in the Medicare program. The private health plan Harvard Pilgrim Health Care refused to allow three concierge physicians into its network because it expected that doctors who participated in the network should provide twenty-four-hour access and same-day appointments when appropriate and not charge extra for those services. Many concierge physicians opt to drop all health insurance participation to avoid running
afoul of regulators and insurers.


Although concierge patients may feel they are receiving higher quality health care because they have more physician time and attention, there is no scientific evidence at this time to support that assumption.

On the contrary, it is possible that as the doctor spends more time caring for fewer patients, his clinical skills may worsen because of decreased volume and exposure to different patients. If your physician starts to practice concierge medicine, understand that any future contact with your physician may require payment or a
retainer prior to you receiving any additional care or service not covered by insurance. Since most concierge physicians are no longer paid by insurance companies, this cost comes directly to you. And if you choose not to continue care, it is your physician’s responsibility to help you find another doctor.

Should you take part in a concierge practice? It depends. If you can afford it and you enjoy the personal attention and pampering, concierge medical care might be right for you. Your physician is on a retainer and essentially is on your payroll as a paid consultant. Direct access to your doctor, long comprehensive office visits, and same-day appointments can’t be beat.

Or can it? With a bit more time and energy, you can get similar care for less money. Instead of an hour-long consultation with a concierge doctor, you could get the same amount of face time with your regular doctor over a period of three to four separate office visits. The latter would certainly be more inconvenient, however.  The bottom line is that only you can determine how much the extra convenience of concierge care is worth. The lowest retainer for concierge care runs about $600 per person per year. If your current office co-pay costs $20 to $30 per visit, you could see your regular doctor twenty to thirty times for the same amount of money. Also be aware that more and more physicians are working on open-access scheduling. This system focuses on providing patients with same-day appointments, which has improved satisfaction among patients and physicians.  With more physicians adopting this mindset, the same-day access benefit touted by concierge medicine may be less of a deciding factor.

Will concierge medicine be successful? Time will tell.

As much as I understand the attraction to many primary care doctors as well as medical students, I am quite pleased with my own practice and have no intention of joining a concierge boutique either as a doctor or as a patient.  Despite the benefit provided by concierge patients at the Tufts Medical Center to assist other patients, ultimately its existence simply widens the gap between the haves and the have-nots.  Whether the have-nots can continue to receive benefits from the philanthropy and willingness of others to pay even more above their health insurance premiums will depend on if healthcare continues to be increasingly unaffordable.  Unless the healthcare costs change, no one will be able to afford anything let alone concierge medicine.

Tuesday, August 24, 2010

Why the Solution to the Primary Care Crisis, the Patient Centered Medical Home, Will Fail

Everyone understands the need for a robust primary care workforce in making healthcare more affordable and accessible while keeping those in our care healthy.   With the aging of America and healthcare reform, even more Americans will need primary care doctors at precisely the same time doctors are leaving the specialty in droves and medical students shun the career choice.  So as a practicing primary care doctor, I've watched with great interest the solutions for the primary care crisis.

I've been utterly disappointed.

Patients so far don't like the patient-centered medical home (PCMH) as noted in Dr. Pauline Chen's New York Times column.  The changes recommended won't inspire the next generation of doctors to become internists and family doctors.  Experts understandably look at a dwindling workforce and unprecedented demand to come up with solutions like (from the May 2010 Health Affairs article - Transforming Primary Care: From Past Practice to The Practice of The Future):

  • "physicians can no longer enjoy trusting relationships with all of their patients.  Just as tasks must be shared among the primary care team, the joy of personal interactions with patients must also be shared."
  • "no contact at all with patients having uncomplicated needs.  The new primary care practitioner would function as a team leader and clinical teacher rather than as a healer to all who seek help."
  • "nurse practitioners and physician assistants could take responsibility for common acute and chronic care issues."
  • "small practices without a robust team would be limited in their capacity to institute such team-based care [for preventive and chronic conditions]".
  • "the primary care practice of the future must adapt to the reality of large panels - the number of patients under the care of a single doctor."
  • "models in the United Kingdom that have employed longer visit times with advanced-practice clinicians, patient satisfaction is high."

I wouldn't want to do primary care either as a practicing doctor or as a medical student contemplating a future career.  Having a larger panel size isn't attractive in a field lacking work-life balance. Putting aside the issues of reimbursement and medical school debt, which also need to be fixed, what experts have fundamentally failed to appreciate is that these solutions perpetuate the cottage industry that they so desperately need to transform.

First, Americans are not like people from Great Britain.  Americans are uniquely different. We have our own views.  Note how rapidly we've adopted the metric system.  Though the British may have high satisfaction with non-physician providers, given a choice and a level playing field of the same amount of time and access, I believe Americans will choose a doctor over a nurse practitioner (NP) or physician assistant (PA).  Telling future doctors that they can't see young and healthy individuals for acute problems not only makes them highly unlikely to choose primary care, it also will be quite upsetting for the general public.  As other articles have noted, NPs and PAs numbers are also insufficient to close the gap of an overwhelmed primary care workforce.

Second, stop rebuilding and perpetuating the cottage industry and reinforcing the fragmentation of primary care.  Except for very small medical practices like the ideal medical practice model where there is only one doctor with no staff, supported with technology, and extremely low overhead, having all primary care doctor offices create a team of staff to care for chronic conditions is absurd.    It isn't scalable.  Three quarters of primary care doctors are in either solo to five person practices.  Each doctor office shouldn't re-invent the wheel.  Instead, third party organizations should be accountable for managing chronic conditions and reporting to a patient's primary care doctor if the patient is not compliant with care or not following practice protocols.  Employer groups are leading this change as well.  This is a good thing. 


The article "Prospects For Rebuilding Primary Care Using The Patient-Centered Medical Home" notes that taking payments to invest in a "community-based organization provides infrastructure, such as care coordination services, that can be shared among several primary care offices" is already occurring in North Carolina and Vermont.  In addition, "local virtual organizations might consist of networks of small independent practices or of practicies affiliated with a hospital.  They could be linked through sharing of care management health IT or human resource for case management or care coordination."  These are ideas that must be pursued.  Few doctors want to be the doctor, the clinical chronic conditions leader, and the IT expert yet this is what most articles of the PCHM propose.

Having infrastructure that is scalable and seemless via health IT will off load both chronic conditions and preventive care to these other organizations which can assist doctors in providing the right care.  As a result, a doctor with an average panel size of 2000 is free of the 17.4 hours per day needed to do it alone.  This time is now available to do what primary care doctors were trained to do, to evaluate patients with problems that don't quite fit standardization or protocols.   Opportunities to see those who are young and healthy if they wish to be seen even if a protocol could treat a bladder infection over the phone or email are possible.  Patients and doctors would find this encounters far more satisfying.  One thing these third party groups must do is to agree to common reporting standards rather than proprietary ones to make the evaluation of clinical data quick and easy. 

An area which is already being carved out of a primary care office is the acute care provided by retail clinics like Minute Clinic as well as start-ups like Zipnosis.  Focused on a subset of problems where protocols are developed delivers care more rapidly and at less cost.  Primary care doctor offices can either try to replicate this as well or perhaps better would be having the healthcare system virtual integrate these providers offering precision medicine (protocols) with primary care doctor offices who do intuitive medicine (cognitive / clinical decision making).

So what does this all mean?  Avoiding the discussion of the federal government's role of community clinics, the future of primary care will thrive in three areas: large integrated healthcare systems like Kaiser Permanente, individual doctor offices virtually integrated by third party vendors as well as other non-physician providers like retail clinics, and the solo practitioner doing the ideal medical practice.

My fear, however, is that this won't happen.  Instead, medical students will be more appalled with the future vision of primary care, fewer doctors will be in the workforce, patients continue to bypass primary care doctors, and the unthinkable crisis that experts are trying to avoid in fact occur more rapidly.

I hope I'm wrong.

Thursday, August 19, 2010

Dr. Frank Ryan Car Accident - Learning From His Tragedy

I'll be honest.  I never heard of Dr. Frank Ryan, a Hollywood plastic surgeon, until his tragic motor vehicle accident recently.  Clients included actress Heidi Montag and boxer Oscar De La Hoya.

Although the California Highway Patrol investigation is not complete, rumors have suggested that Dr. Ryan might have been text messaging when driving.  If this is true and a well-trained intelligent doctor can fall prey to allure of technology, then what does it mean for the rest of us?

First, realize that we can't multitask.  You have one brain. You can focus at one task at a time.  Though laws allow hands-free cellphone calls, the issue isn't trying to dial the phone but rather that the mind is engaged in the conversation and not on the road.  Yes, we are all increasingly busy, but we can't multitask.  In fact, researchers have found that it takes more time and effort to re-focus when we are distracted from one task to the other.

So have a hard and fast rule.  The cell phone is off when driving.  You don't need to answer phone calls when doing something important; that is what voice mail is for.  The FAA requires airline pilots to follow the sterile cockpit concept for flight under 10,000 feet when communications is restricted to essential communications.  Failure to abide to this regulation was thought to play a role in the Continential Connection Airlines crash in Feburary 2009 near Buffalo, NY. 

It should be obvious that the same goes for text messaging.

Also, get a safe car.  The Insurance Institute for Highway Safety rates cars annually for crashworthiness.  Some reports indicated that Dr. Ryan was driving a 1995 Jeep Wrangler when it ran off the Pacific Coast Highway.  For Jeep Wrangler years 1997 to 2006, the crashworthiness for frontal offset impact was deemed acceptable.  There was no safety rating for roof integrity.  There is no data for 1995.

All vehicles even built by the same manufacturer and same model can differ based on the year.  Not all Jeep models received good or acceptable ratings for frontal offset impact.  Both Cherokee and Grand Cherokee year 1997 to 2001 and 1996 to 2004 respectively received a marginal rating, just one step better than poor.  However, the 2011 Grand Cherokee was rated a best pick for safety and received a good rating for frontal offset and roof integrity.

Obviously a Grand Cherokee isn't quite as fun to drive in Malibu but may have been safer.

Clearly, Dr. Ryan died too early.  Even though famous for his Hollywood clientle, he also did a lot of important charitable work for those who didn't have as much.  The fact that they won't have his services in the future is the real tragedy.

Wednesday, August 11, 2010

Water Safety - Drowning Kids Don't Scream



This summer I learned a couple of very important lessons. Drowning kids don't scream. Mothers have a sixth sense even when it's not their own child.

On a beautiful warm sunny day in San Diego, my family and our good friends were enjoying a well-deserved vacation.  My five year old daughter was splashing around with her friends as their father and I observed them from the pool.  Though he had to watch three kids, one was already on a swim team and the two younger children had followed their big sister in swim class.  He also had some help.  His wife was watching the kids from her chair.  The scene was certainly picturesque, serene, and unassuming.  Children playing happily in the pool.  Adults relaxing and talking.  It was a great day to be away from home and work.

Who would realize that nearby, a little boy would be in serious trouble?

In a moment his wife bolted from her chair, arm reaching out to grab a little boy. Both my friend and I were confused what was exactly happening.  There was no splashing.  No screaming.  Simply silent bobbing.  

He was drowning.

He was just a little bit beyond her reach.

The boy's father suddenly aware of the situation jumped into the pool fully clothed.  He lifted his son out of the water, which was only four feet deep.  Understandably stressed, the father admonished the boy.

"What do you think you were doing?"

I'm sure the little boy was equally as scared, though he probably wasn't aware of what could have happened.  He might have been only three years old.

Though the father thanked my friend and defended himself in not being a "bad parent", we wondered the same thing and were equally as outraged.

"What do you think you were doing?"

How could you put your child in an situation where he can't possibly succeed?  He can't swim.  He isn't wearing a life jacket.  He isn't being supervised or watched.  He's too short to be in the pool.

Drowning is the second leading cause of death for children between the ages of 1 to 19.  In 2006, 1100 children died.  The American Academy of Pediatrics has recommended that children age 4 years and older learn how to swim and recently shifted their position of being against swim classes for children between 1 to 3 years old to having parents make an individual determination.  This change reflects some evidence that children in that age group were less likely to drown with some swim instruction.

Water safety is so important that even though we don't even own a pool, my nearly three year old son attended his first swim class a couple of weeks ago.  One on one in a positive safe environment and with me in the pool, his instructor had him place his head under water.  Sometimes prepped and sometimes not.

When his head popped up, he spit and sputtered particularly when he didn't know she was gently bringing him under water.  He coughed for a second or two.  A little annoyed with a brief cry, he happily played with the many pool toys scattered around the pool.  She showed him how to spit out the water.  He copied her.  Throughout the 15 minute class, his instructor showed how a perpetually smiling Buzz Lightyear enjoyed having his head fully immersed.    

But having him under water without warning?  Why did she do that?

She explained that for children to be safe because they might fall into water unexpectedly and to prevent drowning, it is important they are conditioned to react correctly and instinctively.  They won't have time to prepare themselves.  Think of it as a dress rehearsal for the real thing.

I hope his father understands the importance now and will enroll his child in a swim class.

Thank goodness for a vigilant mother and board-certified pediatrician.  Although all three of us are doctors and have plenty of training as either a pediatrician or family doctor, none of us want to be in a situation where we can't win.

Performing CPR on a little boy who deserved a lot better.

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