Wednesday, July 27, 2011

Are Patients Becoming Day Traders?

Let me say first that I am a practicing primary care doctor who is very much focused on patient centered care.  Though I cannot go back to being a patient who is unaware about what a doctor does, the terminology she uses, or what the importance of certain test results are, I can empathize with the overwhelming amounts of information, challenges, and stressors patients and families can have in navigating the healthcare system to get the right care.  This is the reason I wrote my book.

However, over the past few months I've noticed a particularly disturbing trend.  Patients are not consulting doctors for advice, but rather demanding testing for diagnoses which are not even remote possibilities.  A little knowledge can be dangerous particularly in the context of little to no clinical experience.  Where many patients are today are where medical students are at the end of their second year - lots of book knowledge but little to no real world experience.

More patients are becoming the day traders of the boom.  Everyone has a hot stock tip, only now it is "be sure to ask your doctor for this test" or "ask for this medication because it is the only one that works".  Everyone is an expert with his own suggestion on what should be done.  If a medical expert, like a doctor, weighs in and does not agree, then there is a set of patients and doctors who begin to argue that these doctors are out of touch or arrogant.


I certainly agree that many doctors frown upon their patients doing research online.  I disagree with my colleagues.  I'm all for patients being partners in their health as long as when they research they also go to reputable websites, like the Mayo Clinic or Kaiser Permanente, and also give equal weight to my medical advice.  Ultimately, patients should be more knowledgeable about their health and engage not only with doctors, but with family and friends as health does not begin with doctors, but in households and communities.  However, today's world is increasingly polarized due to the ability to gather information and find opinions of like minded people quickly and easily.  A patient researching information can unwittingly blind themselves into believing that a medication, a treatment, a test, or a diagnosis is the only one that explains their symptoms. 

Many of the patients who Google their symptoms, do cursory research, and are so convinced that they have a particular problem and need a particular solution are the group I worry about the most.  They want to see a specialist for a problem adequately handled in primary care.  They want a branded medication when a generic medication works equally as well.  They want CT scans and MRIs for migraine headaches or sprained ankles when a generation ago, doctors and patients believed diagnoses based on common sense.  They decline vaccinations for preventable illnesses like pertussis, whooping cough, because they are healthy and don't want "chemicals" even though the state they live in had the worst outbreak of pertussis since 1955.

With more Americans paying for their health insurance through higher copays for doctor visits, medications, imaging, and treatment, it is understandable that they want more information and are seeking it.  What is particularly troubling, however, is much like the day traders of years ago, many are bypassing experts for some advice and consultation.  Indeed a decade ago many ridiculed financial guru Warren Buffet for failing to understanding the new world and being a dinosaur.  Principles of the past no longer applied.  (Of course, financials principles remained - you do need to make money to be an ongoing company).  As a front line doctor, I'm seeing the same phenomenon in health care.  Doctors still clinch the right diagnoses by talking to and then examining patients.  Skipping directly to lab work or imaging often gets the wrong answer.  Sometimes there is no test or imaging study that can get the diagnosis.  Yet somehow if asked, patients retort I don't have money to see you, I'd rather spend the money on the test or medication, so can you order it?

Like the day traders of a decade ago, these individuals have the illusion of control or mastery.  Only later do they discover when the results are normal and the problem remains that being an expert and having the ability to take in information, process it, and then come up with a plan is harder than it looks.  (Dr. Lisa Sanders, whose New York Times series Diagnosis was the inspiration for the television show House, M.D., has excellent patient cases which challenge the public on getting the right diagnosis).

That is not to say that there are not patients who are indeed experts.  The individuals who are leading the empowered patient movement often know a lot about their diagnoses and treatment options and have mutual respect from their doctors.  Enlightened doctors realize that they cannot know it all.  I would hope and believe that empowered patients also recognize this inherent problem in themselves as they also cannot know it all either.  It is the rich discussion and collaboration which occurs when both groups are on relatively equal footing in terms of knowledge that the answers, solutions, and treatment plans are far better than if only one side or the other led the conversation.  Those patient experts probably can and have identified their condition when they read it in Dr. Sander's column.

Who would have guessed that the day traders of the past would now appear as patients?  Funny and sad how history repeats itself.  The difference is unlike money the stakes are significantly higher when it comes to health.

Not sure what to do when you have a problem?  It's ok to research online, but then have an open mind when talking to your doctor.  If your doctor does not want to listen, then find another one.  Be sure, however, as you research and listen, that you do not become a day trader.  Indeed, if not done correctly the consumer driven health care movement has the potential to be equally as problematic as the retirement planning and investing movement a decade ago.

Tuesday, July 5, 2011

Required Reading for Medical Students, Interns, and Residents.

I have had the privilege of working at an organization which is actively improving the lives of its members and also was mentioned by the President as a model for the nation.  Over the past few years, I have also demonstrated to first year medical students what 21st century primary care should look and feel like - a fully comprehensive medical record, secure email to patients, support from specialists, and assistance from chronic conditions staff.

But as my students know, there are also some suggested reading assignments.  I'm not talking about Harrison's or other more traditional textbooks related to medical education.  If the United States is to have a viable and functioning health care system, then it will need every single physician to be engaged and involved.  I'm not just helping train the next group of doctors (and hopefully primary care doctors), but the next generation of physician leaders.

Here are the books listed in order of recommended reading, from easiest to most difficult.  Combined these books offer an understanding the complexity of the problem, the importance of language in diagnosing a patient, the mindset that we can do better, and the solution to fixing the health care system.

Which additional books or articles do you think current and future doctors should know?

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer
Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

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

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

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

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

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

If there is an area of disagreement, then it is the fact that Dr. Jerome Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, yet Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence.

As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating.

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

Better: A Surgeon's Notes on Performance
A fascinating and quick read.   In each section there are plenty of inspiring stores about doctors making a difference. Dr. Atul Gawande, a general surgeon at Brigham and Women's Hospital and staff writer for the New Yorker has keen observation and insight to make single stories demonstrate not only the failings of our healthcare system but also the solutions to them because of individuals asking questions on how to do better. Ultimately, one of the questions he asks is how can doctors and hospitals be positive deviants? How does one become a positive deviant or an outlier that pushes beyond convention and advances patient care to new levels?

He gives examples of how over four million children need to be vaccinated in Northern/Southern India in three days to prevent a large polio outbreak. An immunization rate of less than 90 percent would be considered a failure.

Dr. Gawande talked about the evolution of obstetrics. After a damaging report in 1933, the specialty consequently committed itself to standardizing childbirth ensuring that with the new medical knowledge that it was applied consistently and routinely throughout the country. As a result maternal death in childbirth fell 90 percent from one in 150 in the 1930s to one in 2000 by 1950s. With continued innovations and the commitment to do better, the chance of a woman dying in childbirth is less than one in 10,000 today.

There are plenty of amazing examples that you don't have to be a doctor to relate on how truly inspirational these individuals are in times when the stakes could not be higher - life or death.

Until our healthcare system improves to its full potential as Dr. Gawande challenges us to do, unfortunately will always remain benefiting those who are insiders and harming those who are not. The real question is which one are you?  This failing is part of the reason for the rise of the empowered patient movement.

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 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. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS 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.


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