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 dot.com 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.

Hardly.

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.

e-Patients, Dr. Google, Your Doctor, and You

A recent article by NPR confirmed what many patients and doctors already know. The internet is leveling the playing field and allows individuals to access information easier and more quickly. Research by Pew Internet and American Life Project found:

• 61 percent of adults say they look online for health information - known as e-patients
• 20 percent of e-patients go to Internet and social-networking sites where they can talk to medical experts and other patients
• 39 percent of e-patients already use a social-networking site like Facebook
  

Yet as individuals embrace new technology, the New England Journal of Medicine found earlier this year that only 17 percent of doctors use electronic medical records. To say doctors are conservative and slow in adapting to new ways of communicating and accessing information would be an understatement. An article in TIME magazine proclaimed "Email Your Doctor" which graced newsstands in 1998! Email communications with doctors is still the exception rather than the rule.

Many doctors actually are very concerned about patients using the internet to research information. Stories of physicians being inundated with printouts or patients insistent that they have a certain diagnosis based on a description abound. Doctors don't always appreciate patients googling their medical information.

Why?

Because although information gathering is far easier than a decade ago, the problem is data overload. How does one filter out all of the different diagnoses with similar symptoms? How does one use judgment when theirs is based on little experience? Medical students commonly come down with medical illnesses after studying a subject. It's the power of suggestion. Fever and a little neck stiffness? Meningitis. Intermittent numbness in the arm? Multiple sclerosis. Circular rash? Lyme disease.

Only through experience and actually caring for patients diagnosed by more seasoned colleagues do medical students see the textbook descriptions come to life. Patients diagnosed with meningitis, multiple sclerosis, and Lyme disease and their associated symptoms and signs are seared into students' memories. Words in the textbook now have far different meanings. Reading and book learning while important only provides the foundation to build upon. It's seeing and doing that matter.

Doctors can't know everything. So it can be helpful if you research information and bring in some ideas or questions that you have about a particular diagnosis. I know patients are more empowered with more information, but realize there is still value in clinical expertise. Have a frank discussion with your doctor whether the information obtained by Dr. Google is accurate or relevant to your concerns. Keep an open mind. Don't be anchored by what you read. I certainly learn from my patients. My patients learn from me. It's a win-win.

While the internet can make anyone more knowledgeable, it doesn't make someone an expert. The good news is that the survey found in the end that the source people still trust the most is their doctor. So go ahead research, but find reputable sources like the Mayo Clinic or Medline Plus. Talk to your doctor and perhaps email him. Gain from both knowledge tempered with expertise.

As we all gather around for Thanksgiving, savor the time with family and friends. While I would never be mistaken for a chef, let alone a good cook, I will be making a delicious butternut squash soup which is a new Thanksgiving tradition. The recipe? Courtesy of the internet and Wolfgang Puck. How hard could it be? I finished organic chemistry.

Doctors Critical To Save Healthcare System, But Will They? Doubtful.

Two critical articles over the past few weeks give a good sense of where our healthcare system will be in a decade and it isn't good.

An insightful survey from the Kaiser Family Foundation, NPR, and the Harvard School of Public Health asked the public about key issues currently tossed around the topic of healthcare reform including the use of electronic medical records, coordination of care, and also comparative effectiveness. The report titled The Public and the Health Care Delivery System demonstrates the great disconnect from reality. If we were as good in delivering and coordinating care as the public believes, the United States would be the first among industrialized countries in health quality outcomes like cancer screening, blood pressure and cholesterol control, and infant survival, rather than last.

Books like Overtreated have illustrated quite convincingly that we fail to do basic proven treatments routinely in our country and we often don't provide the least expensive option which is equally as effective as more pricey options.

But the public doesn't think so. Perception is reality regardless of the truth.

From the survey, these questions show that the majority of Americans believe, wrongly I might add, that doctors recommend less expensive therapies which are equally as effective as more expensive ones.

Q28. In the past two years, do you think your doctor has ever recommended an expensive
medical test or treatment for you when a less expensive alternative would work just as
well, or hasn’t this happened?

• 9 Yes, doctor has recommended expensive treatment when less
• expensive alternative would work just as well
• 87 No, this hasn’t happened
• 4 Don’t know
• -- Refused

The public wrongly believes that in the majority of cases, the right care and scientific evidence is not available on how to treat certain illnesses, when in fact there is more precision and diagnostic ability.

Q13. When doctors make decisions between different treatment options for a patient, do you
think there is usually CLEAR scientific evidence about which treatment is likely to work
best, or do you think the scientific evidence is not always clear about which will work
best?

• 23 Usually clear scientific evidence
• 72 Scientific evidence is not always clear
• 5 Don’t know
• * Refused

Doctors often use medications that are "off-label" not approved by the FDA or backed by clinical trials. Although in the case of cancer, this might be acceptable, there are plenty of examples that this is deadly and dangerous. About a decade ago, it was touted that the best chance for survival for a woman with metastatic breast cancer was a bone marrow transplant, that is, wipe out the entire immune system, and transplant a new immune system with stem cells. It worked for blood cancers, like leukemia. Tragically, there was never any evidence and the only one study that showed survival advantage the investigator made up data. Women died unnecessarily from complications of the bone marrow transplant and over time we discovered they did worse, not better, not even as well as those who chose "traditional" chemotherapy and treatment.

Yet, women were clamoring to get the procedure done (thankfully no one does now, I hope...). Who held the line? Insurance companies noting that there was no scientific research. Naturally and understandably people went to the press and insurance companies buckled under mounting pressure that they were denying care. But do doctors really make the right choice for you? For the record, I don't believe in for profit health insurance companies.

Q15. If your doctor recommends an expensive medical treatment, but it has not been proven
to be more effective than other, less expensive treatments, do you think your
insurance company should have to pay for it, or not?
Based on one half of total respondents (N=619)

• 55 Insurance companies should have to pay for it
• 38 Insurance companies should not have to pay for it
• 4 (Vol.) Depends
• 3 Don’t know
• * Refused

Doctors can't say no and we can't even provide you the least expensive care which is equally as effective. Why? Part of the reason is how the majority of doctors are reimbursed. The more they do, the more they get paid. Why would they ever say no to you? You might not come back. Also, it's no skin off their back as the costs don't come out of their pocket. Of course, it does increasingly come out of yours. But you aren't equipped to make the right decisions on when to skip and when you need to spend to get better.

Q30. In the past two years, has a doctor denied you a medical test or treatment that you
wanted because they thought it was not medically necessary, or not?

• 10 Doctor has denied medical test or treatment you wanted
• 89 Doctor has not denied medical test or treatment you wanted
• 1 Don’t know
• * Refused

This last question is the most important. The public feels that doctors try to keep the cost of health care down for the individual, yet from the previous question it is clear that what you want, you get. Fact is we spend more per capita than any other industrialized country in the world and aren't even healthier for it, that is, we die sooner!

23. Do you think your doctor tries to keep the cost of health care down for you, or not?

• 63 Doctor tries to keep cost of health care down
• 29 Doctor does not try to keep costs of health care down
• 1 (Vol.) Don’t have a doctor
• 7 Don’t know
• * Refused

The second piece an article by Dr. Atul Gawande in the New Yorker, The Cost Conundrum - What a Texas town can teach us about health care illustrates that it is doctors that dictate the rising costs of healthcare. Until we align and change the delivery system so that they will do more of the right thing, that is recommend the most effective care, not necessarily the most expensive when a least pricey one will work, and when we make doctors accountable for the entire healthcare system not just piecemeal will we have money to cover all Americans and have everyone be healthier.

The type of reform, which Dr. Gawande notes is the most important, would require doctors to say no to patient requests to unproven treatments or the latest heavily marketed medication (can you say Vioxx?). Are we capable of doing that? 89% of the time we can't rather we let insurance companies do that. Will doctors routinely provide treatment based on scientific evidence and based on effectiveness as well as cost rather than relying on drug reps touting their latest products and free samples?

Unfortunately, I tend to agree with Dr. Gawande. I think the country will not have more Mayo Clinics even though it is the right thing to do because frankly the type of reform needed may be too much for our doctors as they now need to have candid but important conversations about effectiveness and cost in a country always fooled into thinking newer is sexier and better, when in medicine that is far from the case.

Excerpts from the article -

It is spring in McAllen, Texas. The morning sun is warm. The streets are lined with palm trees and pickup trucks. McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent. McAllen calls itself the Square Dance Capital of the World. “Lonesome Dove” was set around here.

McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami—which has much higher labor and living costs—spends more per person on health care. In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.

...Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do.

...The real puzzle of American health care, I realized on the airplane home, is not why McAllen is different from El Paso. It’s why El Paso isn’t like McAllen. Every incentive in the system is an invitation to go the way McAllen has gone. Yet, across the country, large numbers of communities have managed to control their health costs rather than ratchet them up.

I talked to Denis Cortese, the C.E.O. of the Mayo Clinic, which is among the highest-quality, lowest-cost health-care systems in the country.

The core tenet of the Mayo Clinic is “The needs of the patient come first”—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients...

The Mayo Clinic is not an aberration...

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

This last point is vital... When it comes to making care better and cheaper, changing who pays the doctor will make no more difference than changing who pays the electrician. The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

...In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue.

...As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.