Friday, July 30, 2010

Americans Cut Back on Doctor Visits - Very Worrisome

The Wall Street Journal reported that overall medical use fell as patients had fewer doctor office visits, lab testing, and maintenance medications possibly due to the recession or as a result of consumer driven healthcare in the way of higher deductibles and copays.  This is very worrisome.  Certainly patients should have some financial responsibility for their care, but skimping on care will only result in Americans not becoming healthier, but sicker.  Though the article cited some examples of patients saving money by not seeing their allergist for a refill of medication and simply calling for one and getting an athletic physical at a local urgent care clinic for $40 rather than $90 at the doctor's office, these tiny behavior changes aren't going to bend the cost curve in medical care.

Sure, some patients are holding off on elective surgeries.  This might be a good thing as research has suggested that Americans get too many procedures compared to other industrialized countries.  However, this could be equally as bad as there may be an equal number of people who truly need surgery to improve their quality of life and ability to walk but can't do so because they can't afford it.

With more financial responsibility of higher deductibles and copays, patients will simply skip care, specifically, needed medical care.  As the drugstore CVS noted, there was a "drop-off in new prescriptions for maintenance drugs tied to a decline in physician visits".  In other words, patients are not getting treated for their high cholesterol, high blood pressure, or diabetes to prevent premature heart attacks or strokes.

Paul Ginsburg, a respected health economist of the Center for Studying Health System Change noted that this patient behavior "could go beyond the recession. Being a less aggressive consumer of health care is here to stay."

I disagree with him in the sense that patients weren't necessarily aggressive before, but behaved in a rational manner when copays were low, there were no costs to medications, lab work, and office visits.  The question is with very high financial barriers to seek care will they make the right choices?  Will Americans change their behavior and become healthier?

The answer is no.

As a practicing primary care doctor I know when I must seek medical care and when I can safely skip.  If this data holds true for the next few years, America will have a very big problem.   We will have a less healthy workforce because they cut corners on their health.  A generation of Americans who will skip important preventive screening tests because they feel fine and aren't willing to pay the high copays.  Those with medical conditions like diabetes will develop avoidable complications of blindness, kidney failure, and amputations because patients don't renew their maintenance medications.

Americans will die sooner, have a worse quality of life, and more preventable complications as a result of consumer driven healthcare.  The doctors who are best in advising patients on the right care, the primary care doctors like internists and family doctors, are leaving their practice in droves because of issues of work-life balance and decreasing reimbursement.  Healthcare costs for the short-term may fall only to rise rapidly as patients are forced to be treated for conditions that could have been handled earlier more easily and for a lot less.

In other words, the perfect storm of a worsening healthcare system is upon us soon.

Which will leave the government no choice but to establish a single payer government run system.

Monday, July 26, 2010

New Pap Smear Guidelines - Rationing Healthcare or the Right Care?

The American Congress of Obstetricians and Gynecologists (ACOG) recently reiterated their position that Pap smear should be performed on healthy women starting at age 21. This is different from the past which recommended screening for cervical cancer at either three years after the time a woman became sexually active or age 21, whichever occurred first.

How will the public respond to this change?

Over the past year there have been plenty of announcements from the medical profession regarding to the appropriateness of PSA screening for prostate cancer and the timing of mammogram screening for breast cancer. Understandably some people may view these changes in recommendations as the rationing of American healthcare.

They should instead, however, welcome these advancements. Doctors becoming even better at understanding which screening tests work and which ones don't.

Doctors have discovered that for cervical cancer, which is detected by Pap smears, a significant risk factor in infection from the human papilloma virus (HPV). HPV is the most common sexually transmitted disease and aside from causing cervical cancer are also the cause of genital warts. Women under age 21, who are healthy and do not have a compromised immune system from HIV or organ transplant, rarely develop cervical cancer from HPV infection.

Unlike the past when women needed annual pap smears, advances in screening with new liquid-based Pap smears as well as screening for HPV allows women to be checked for cervical cancer every other year. Women age 30 and older who have had three normal pap smears in a row can have Pap smears every two to three years with a Pap smear or every three years with a Pap test and HPV DNA screening.

If all doctors recommended these interventions, this would reduce the number of Pap smears needed by 50 percent. The newest cervical cancer screening method would be far better as it identified which women were at risk with better precision and information than the past. By doing fewer unnecessary Pap smears, doctors are now free to address other problems as well as begin to take on the millions of Americans who will have health insurance due to reform.

The question is will they do it? Will women accept the new changes in screening intervals?

Research shows it takes about 17 years before results of studies and guidelines become commonly practiced in the community. One study showed primary care doctors were not particularly good at screening for colon cancer though new guidelines have been around for a decade.

It's easy to blame doctors for being slow to change. It's easy to blame patients for being slow to change. Many of my patients still demand an annual pap smear even though HPV DNA testing is something my colleagues and I have practiced for years.

The fact is that change is hard unless of course you are new to something. As my five year old daughter proudly told me recently there are exactly EIGHT planets not nine in the solar system.

For the next generation of women, they will not need Pap smears until age 21. They can be safely screened every other year. There is a chance that none of them will never develop cervical cancer as since 2006, HPV vaccines exist for individuals age 9 to 26 that immunize them from the subtypes of HPV that cause cancer.

These women won't get upset. They won't get worried.

They know this is the right care. This is not rationed care.

That is, of course, until the next revision in the guidelines and recommendations.

Monday, July 19, 2010

What Steve Jobs and iPhone 4 Antennagate can Teach Doctors and Patients

First, I am a big admirer of Apple CEO Steve Jobs for his thoughtful 2005 Stanford commencement speech, his clarity of vision, and his superb skills as a leader. Fortune magazine named him CEO of the decade after turning around the company he founded from near bankruptcy in the late 1990s to becoming the most valued company today. Though I have great respect for him, I haven't bought an Apple product, ever, until this year.

So I watched with great interest his press conference regarding Antennagate which has consumed technology news with regards to the design of the new iPhone 4 and its new antenna design. Apparently this makes the smartphone vulnerable to dropping phone calls when held a certain way, known as the death grip. If one simply avoided holding the phone that one explicit way, the phone otherwise worked fine. As a result, 22 days after the latest iPhone was available to the public, Jobs and Apple were instead addressing an issue which dwarfed their latest product launch.

Doctors and patients can learn plenty by watching Jobs approach to the problem because the situation he and his team were tackling is similar to what a doctor addresses daily in the office.

  • Perception is reality regardless of the truth.
  • Hard data is important to have candid conversation. Specifically the right data.
  • Sometimes emotions are so overwhelming that something needs to be done. This can be good or bad.
  • People who advocate certain positions have inherent biases, which can make their argument far from objective, hence the need for hard data and expertise to interpret.

With all of the negative press, Jobs figured that a reasonable person might figure that about 50 percent of iPhone users would complain of dropped calls or that a significant number would return them. The hard data from Apple shows that only 0.55 percent of calls to their customer service center were in regards to phone call reception and that 1.7 percent of iPhone 4s have been turned. This return rate was far lower than the 6 percent observed last year during the iPhone 3GS launch.

Although Jobs noted that there were plenty of opinions about the possible reasons and solutions for the problem, the press conference was convened nearly three weeks after launch because Apple engineers needed time to understand the issue fully. As revolutionary as the iPhone 4 is, the very small technical issue which affected a very small number of users became a firestorm. Jobs announced free cases to all iPhone 4 users which seems to mitigate the problem even though the vast majority of users have no problems. He reiterated that new owners unhappy with the phone could return it for a full refund within 30 days. In the end, Jobs reflected that he and the people at Apple work extremely hard to keep their users happy.

Doctors address these issues daily which come up in conversations with patients. This could be in regards to the risk and benefits of immunizations, the need for antibiotics for possible Lyme disease exposure, or many other concerns where a person can psych himself. The internet can be powerful in arming patients with plenty of information, but fails to provide them experience or medical expertise or the objectivity needed to make a good thoughtful decision. (A good reason why doctors shouldn't take care of their own family members).

With the ongoing economic crisis, many patients are presenting with chest pain. Some are convinced that they have heart disease and won't accept anything less than a heart stress test or other imaging even if based on their symptoms, initial testing (basic labs, chest xray, and EKG), and risk factors (age, gender, smoking status) that the hard data clearly points a problem elsewhere.

At that moment, sometimes doctors are unable to talk a person down from their emotional ledge need to do something to address a patient's piece of mind. This could be a referral to a cardiologist or a basic treadmill test.

Hopefully that resolves the issue, but at what cost? Was it the right thing to do?

If the treadmill is a false positive, this will require a further work-up which may include an invasive cardiac catheterization. Although rare, patients can die from the procedure. Doing a test in a highly unlikely patient would be considered very questionable by many doctors. Will an individual doctor be confident enough to stop the process based mainly on emotion and perception when hard clinical data points in another direction? Is it possible that the tyranny of the short office visit and the need to do something perpetuate the problem and result in further testing?

In this case, all of this was done for stress? Was all of the additional testing and increased risk of harm needed to demonstrate a normal heart?

As Jobs and Apple know, an issue can be blown out of proportion and emotions can run high when perception distorts reality. Free cases are an easy fix.

When it comes to medical care, sometimes the easy fix may require doctors being calm, listening, and spending time to understand a person's concern. Does keeping patients happy and healthy sometimes mean saying no and providing rational thoughtful care?

For patients it means not believing everything they read or hear from friends, family, or the internet (or even other doctors and healthcare providers who only know pieces of information but not the entire story). With increasing financial responsibility through higher deductibles and copays (consumer driven healthcare), will patients listen to doctors who can help make the right decision with their clinical expertise or rely on the information gathered by the internet and demand testing believing that is the right thing to do?

Based on my experience, it doesn't look good. It's getting harder to talk some patients off their ledge.

We could certainly use Jobs and his leadership team in healthcare or least his presentation skills. When asked during Q&A, Jobs and his team pulled out their iPhone 4s - all without an external case.

And yes, my phone works perfectly fine.

Wednesday, July 7, 2010

Cellphones Kill, Just Not With Radiation

San Francisco recently passed a law requiring disclosure to consumers of the amount of radiation emitted by cellphones at the point of sale. Research has been inconclusive on whether there is a linkage between cellphone usage and cancer. More definitive findings could be years away.

Understandably the law addresses a universal concern that we all have. We are more fearful of threats that we can't see, smell, hear, taste, or touch. Radon, carbon monoxide, and radiation fit these criteria.

Yet, cellphones kill in other ways which are far more immediate, equally as subtle, and just as concerning. This silent epidemic is increasing at an alarming rate. Everyone sees it, but does nothing about it.

Cellphones and driving don't mix. Cellphones and walking is probably not a good idea either.

When talking on a cellphone or even a telephone, the user is completely engaged, hooked, and oblivious to any other information or sensory input. Although as a nation we pride ourselves on our productivity, our technology, our lack of sleep, and our ability to multitask, the truth is no one can multitask even though we think we can. Walk up to someone talking on the phone and ask them a question. What do they do? Typically he gestures you to hold on to your question with a raised hand as he focuses on the telephone conversation.

If he can't talk to you at the same time while standing still, then is it safe talking on the cellphone and driving or even crossing the street?

Not surprisingly the answer is no.

A report by the Pew Internet and American Life Project found that 6 in 10 adults talked on cellphones while driving, nearly half of adults were riding in a car when the driver was either talking on the cellphone or text messaging, and 44 percent felt unsafe when riding in the car. Aside from driving, 1 in 6 adults actually bumped into something or someone when talking or texting on a cellphone.

It is clear from the study that more people are putting their lives and yours at risk. Although I rarely use my cellphone, I'm not immune from this epidemic.

Just the other day when driving my daughter to her reading class as I was making a left turn from the designated turn lane, a bright yellow pick-up truck at a high rate of speed ran the red light which had been up for a couple of seconds.

Fortunately, I had stopped before entering the intersection and slammed on my horn to alert the driver of the near miss.

She was on her cellphone. Fully engaged. Completely oblivious to what could have happened. No flicker of acknowledgement that she even heard my car horn.

In other words, it is very likely my small sedan would have been unable to withstand a head-on or side impact collision from a pick-up truck. I shutter to think what might have happened that Sunday morning on Father Day's.

Had police officers responded to the accident scene, the driver invariably would have said, "I don't remember seeing a red light. I don't remember seeing a car in the intersection."

The irony is that she would have been completely right.

She would have walked away unharmed. Very likely clueless that her simple act of talking killed two people. Free to repeat the behavior again.

Do yourself a favor and make sure you are not someone who is a dangerous driver. Make your car a cellphone free zone. Turn it off before entering the vehicle. If you must take a call, then pull off the lane like you would when allowing fire trucks and ambulances the right of way. Even more importantly be very alert for distracted drivers on cellphones. Sixty percent of drivers may be in this group and unfortunately the number will only increase. Hands free devices make no difference in improving safety. The brain and user is fully hooked to the conversation and unable to see beyond the call.

Look both ways before crossing the street when walking or driving into an intersection. Boring, basic, and even more necessary.

As for me, I think I might be able to find a Hummer for cheap.


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