NYT Kristof's A Possibly Fatal Mistake Shows Future of Health Care. It Isn't Good.

NY Times columnist Nicholas D. Kristof wrote a heartfelt piece "A Possibly Fatal Mistake" about his college roommate Scott Androes, who recently was diagnosed with metastatic prostate cancer. His story illustrates the problem with the current health care system.  It isn't about the lack of health insurance. It's about the obstacles all patients face in making the right decisions and the right treatment.

Something that will increasingly be harder with consumer driven health care.

Kristof lets his 52 year old friend, who is well-educated (graduate of Harvard, financial and pension consultant) and also was uninsured starting in December 2003, tell the story.

In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.

 

Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”

 

I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)

 

The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. 

Androes, after being diagnosed with metastatic prostate cancer, like most of us, would reflect on what went wrong.

I read Nassim Taleb’s book “The Black Swan” and imbibed his idea that you should keep an eye out for low-probability events that have potentially big consequences, both positive and negative. You insure against the potentially negative ones, like prostate cancer.

So why didn’t I get physicals? Why didn’t I get P.S.A. tests? Why didn’t I get examined when I started having trouble urinating? Partly because of the traditional male delinquency about seeing doctors. I had no regular family doctor; typical bachelor guy behavior.

I had plenty of warning signs, and that’s why I feel like a damned fool. I would give anything to have gone to a doctor in, say, October 2011. It fills me with regret. 

What can we learn about his experience and the future of our health care system?

Smart educated patients can make bad decisions

Androes is highly educated. If anyone should understand the cost benefit analysis of money and health, it should be a pension consultant educated at Harvard. He had opportunities to seek care sooner, but chose not to. Understanding this psychology is important as it is the underpinning of consumer driven health care - patients will choose more rationally if they have more financial skin in the game. Yet all I continue to see is evidence to the contrary.

First, Androes had many obstacles and not all related to lack of health insurance. He didn't choose to see a doctor when symptoms started in October 2011 because the cost didn't seem worth it. This is where our common sense and experience falls short. We've all had experiences of an ache, pain, or symptom. Many go away on their own. Androes like many other patients have this "success" and filed it away. Plus, work is too busy or important to put on hold (another major problem with the economic crisis of 2008) and personal health takes a back seat. The problem is our previous success with other symptoms may not necessarily apply to the current symptom.

It isn't clear if at that point he researched his symptoms with the always available Dr. Google. Unfortunately, like many patients he winged it hoping for the best. Had he thought about it some more, he might have realized that he never had urinary complaints prior to this episode. Having urinary problems are quite uncommon in young or middle-aged men.

So, Androes, like many others, he extrapolated his prior experience to his current situation, which may not have been appropriate.

Who has time to be sick? Don't "bet" on the wrong diagnosis with Dr. Google

Second, when he did have blood in the urine, Androes did consult Dr. Google. Dutifully, Dr. Google pulled up two possibilities. Infection or prostate cancer. Androes "bet" that it was infection. This is no different than "winging" it. Unlike the first episode of urinary problems, Androes clearly is informed about the possibility of cancer. Problem is he can't afford a catastrophic illness like cancer either from a financial or time point of view.

Here is the reality. None of us can afford it. There is never a good time to be diagnosed with cancer or any other serious life-altering illness. Yet is behavior is common among many patients I see. Their job or their financial assets are more important than their health. Androes "chose" to go after April 15th, after tax season, when it was most convenient for him. Dr. Oz nearly made a similarly bad decision regarding his colonoscopy and colon cancer screening a few years ago and then again when he failed to follow-up as recommended for colon cancer surveillance. Part of the reason we all fall into this cognitive trap is that for the most part, our body does a good job in running despite what we eat, our sedentary lifestyle, and long hours of work.
 
The most important financial asset is your health. With good health you can always make more money, with more money you can't buy good health.  So certainly, Androes had his less than optimal choices.

Did doctors miss a chance to diagnose prostate cancer earlier?

What about the health care system and doctors? Did we miss an opportunity?

Yes. It is possible there were two, though unclear if it would have made a difference in his case.

When Androes sought care with a doctor in urgent care and a urologist, he noted the former diagnosed him with a prostate infection and the latter did blood work. It isn't clear whether either doctor did a rectal exam to feel the prostate. A patient with metastatic prostate cancer with a PSA of 1,110 (normal range less than 4) should have a very abnormal prostate exam.

Had a prostate exam been done, either doctor had a very good chance in telling him he had prostate cancer prior to any confirmatory blood work. At that point, however, even with this knowledge it would have been too little and too late to alter the outcome or overall prognosis.

The second issue is whether the benefits of physical examinations or lab testing, like PSA, would have made a difference. Neither have been demonstrated to save lives. In other words, as a nation we might feel better that everyone gets an annual check-up or lab testing, but there is no scientific evidence that either help. Also, as noted previously, it isn't clear patients will seek preventive care for the reasons above.

So, how does this one story, which sadly is repeated too often by different writers and involves different protagonists, predict our health care future?

It does in the following ways:

Common sense does NOT apply to health care- four challenges in making good decisions about health

Common sense does not apply to health care. Patients may have symptoms they have never had before and erroneously assume based on prior experience, that this new problem is nothing to worry about. Denial is a powerful emotion and can cause inaction precisely when action is needed.

Second, when patients feel fine they don't protect against low probability but high risk problems. Will people buy health insurance? Will they demand for preventive screening tests that save lives? Will they willingly get vaccinated against preventive illnesses? Increasingly we see more parents choosing not to have their children immunized and then nationally see many preventive illness, like pertussis, return again with significant consequences.

Third, there are many obstacles preventing good decision making. Whether higher deductibles, copays, or simply working too hard to focus on one's health, people ignore their health until they have no choice or have symptoms. If Androes who had the good fortune of being educated at an elite Ivy League school made poor medical decisions, what are the implications for the rest of society? Patients should be more motivated to take charge of their health, yet it is likely the drive to consumer driven health care will make the nation's overall health care worse, not better. A similar experiment was attempted in retirement planning with devastating outcomes for retirees.

Fourth, people are increasingly devaluing the important of expertise and experience with the increasingly ease and availability of information on the internet. That isn't to say that non-experts cannot make a contribution to furthering progress. The challenge is that the availability of data provides many non-experts a false sense of certainty and absolute truth which is not necessarily true in medicine. We do have genomics, but it is in its infancy. We do have personalized testing, but it isn't clear if knowing the results will be medically important.  When dealing with the complexity of the human body, nuance and ambiguity are prevalent.

More patients are emailing me requesting for CT scans or MRIs because the office visit copay is too expensive. They don't feel that seeing a doctor, taking a detailed history or examination is worth it.

Yet, to counter the issues above it is doctors who can convince people to act in getting testing, treatments, and interventions when they don't want to emotionally or are uncertain what to do. It is doctors who can encourage patients to get preventive testing and immunizations when faced with the overwhelming amount of information and clutter from the media, the internet, and friends. It is doctors who can tell patients when they must seek care and when they can safely skip. There is medical science and then there is everything else.

However, this is not where our country is headed. Too many believe that to lower costs and improve health outcomes, patients must make better decisions. Patients will do so if they have more financial responsibility and more cost transparency.

Show me the evidence because I don't see it.
What I do see, unfortunately, is more cases like Scott Androes.

The Truth About Ovarian Cancer Screening - book excerpt

The New York Times editorial "False Promises on Ovarian Cancer" says it all. What is most concerning is that a third of doctors recommend what medical science shows not to be true: screening for ovarian cancer does NOT work.

Enjoy the excerpt from my book - The Thrifty Patient - Vital Insider Tips to Staying Healthy and Saving Money - and be smarter than 1/3 of doctors! Simple to read and incredibly informative.

Enjoy!

Ovarian Cancer Screening

One of the most feared cancers for many women is ovarian cancer, which occurs in one out of sixty-eight women. Unfortunately, like many cancers (lung, pancreatic), there is no screening test that has been helpful to detect the illness early and reliably proven to save lives.

Until organizations like the American Cancer Society (ACS) recommend certain tests or examinations, everything you may hear on the news or from friends about breakthroughs in screenings is inaccurate.

In the latest update by the American Cancer Society, women are urged to seek medical care if they have had the following symptoms, which could be early signs of ovarian cancer:

• Abdominal swelling or bloating (due to a mass or accumulation of fluid)
• Pelvic pressure or abdominal pain
• Difficulty eating, or a feeling of being full quickly
• Urinary symptoms (having to go urgently or often)

Certainly many benign causes also can cause similar symptoms. If you have these symptoms, they are not typical for you, and you aren’t sure what the cause might be, check with your doctor. The ACS acknowledges that two tests often used to “screen” for ovarian cancer are the blood test CA-125, a tumor marker, and/or a transvaginal ultrasound, an ultrasound probe placed in the vagina to evaluate the ovaries. The update correctly notes that in women at high risk for ovarian cancer and those with no risk, neither test has been shown to save lives.

Unfortunately, until medical researchers find a better and more precise test, women will need to be observant about their bodies. This is the best medical science has in trying to detect ovarian cancer early.

Doctors, Patients, or Insurers - Who Will Shape Health Care?

Recently New Yorker staff writers and best-selling authors Malcolm Gladwell and Atul Gawande addressed the question of whether the problem in health care is that patients are too reliant on doctors and don't have the ability to make decisions. In reading between the lines, is that the reason health care is not affordable and care not commoditized or consumer driven like other industries?

At a conference for America's Health Insurance Plans, Gladwell argued that patients or consumers have been unable to be more empowered because doctors, as the intermediary, held the power of knowledge much the same way chauffeurs did for the early days of the automobile and Xerox technicians did in the early days of photocopying. A person was needed to guide and assist the individual to get the job done. At some point, however, the technology became simpler. People began to drive their own cars and make their own photocopies. The mystique of the chauffeur and technician was lifted. Now everyone could drive. Everyone could make photocopies.

Is it possible that for health care and the health care system, which for many people is a system they interact with rarely and in an area (health / illness) where the uncertainty and stakes many be too "high", that individuals willingly to defer the responsibility to someone else? Gladwell hints that might be a possibility:

"A key step in any kind of technological transition is the acceptance of a temporary deficit in performance at the beginning in exchange for something else," said Gladwell. That something else can eventually include increased convenience and lower cost. He offered a number of examples, including the shift to digital cameras where early pictures were not as good as film and the advent of the digital compression of music, which he contends has made the quality of music worse....

The changes in film and music were accepted, he said, in exchange for new opportunities to arrange, manipulate, and personalize our pictures and music. "In healthcare we don't have the same stomach for that period of transition. That's striking to me."

The disruptive innovation that Gladwell is hoping for has yet to affect healthcare. It is possible that as more Silicon Valley start-ups focus on making medical care more convenient, worry-free, hassle-free, more personalized, and more accessible that the majority of individuals won't adopt them because doctors don't approve. The shift to a "temporary deficit in performance" may not be as acceptable even if less expensive and more convenient. As Gladwell notes in the case of dialysis, despite being around for over seven decades, patients in general still don't self-administer treatment, which would be less expensive, but rather continue to go to facilities which are overseen by doctors.

His colleague, Dr. Atul Gawande, countered that other industries, like "teaching, firefighting, and police work" still have intermediaries that do the work on behalf of the individuals. Gawande believes that the real issue is that the care we provide as doctors isn't integrated. We focus on optimizing each part of the health care system without looking across the entire experience of care. Extending this analogy to building the best car and using the best manufacturer for each part, Gawande notes:

building a car with Porsche brakes, a Ferrari engine, a BMW chassis, and a Volvo body. "Put it all together and what you have is an expensive pile of junk that doesn't go anywhere because the pieces don't work together,"

No where was the need for doctors to lead change and think about the entire experience for the patient more clear than a recent New York times piece by health reporter Tara Parker-Pope, titled "Too Much Medical Care". She chronicled her experience as an educated patient and parent of a daughter who suffered an ankle injury at camp. She started first with:

Pediatrician. Initial visit. 
One month later, still not better so she takes daughter to Sports Medicine specialist. MRI ordered.
Referral to Pediatric Orthopedic Surgeon. Another MRI. Blood work.

Slightly abnormal blood work.
Referral to eye specialist.
Referral to pediatric rheumatologist. More blood work. Another (3rd) MRI. Xray of hands.

Five months after original injury, daughter notes that her ankle still hurts. 

Finally, Parker-Pope takes back control. She consults with the sports medicine specialist who reviews the case with the pediatrician. The focus in back on the patient and pain relief. Soon, the daughter is back to resuming her activity.

In retrospect, what is most surprising is how long the entire process went and still the daughter's problem hadn't been solved. Three MRIs for an ankle injury. Four specialists. Three MRIs. Many blood vials drawn. Xray of the hands, though the ankle was the injured joint. It's not that Parker-Pope is naive or uneducated. She is a health reporter for the New York Times and has talked to many doctors and written many stories. The fact that she and her daughter were caught up in the health care system illustrates the challenges facing the public.

Solving the health care crisis will require both points of view offered by Gladwell and Gawande. We need both patient engagement as well as a more coordinated integrated health care system. It is however increasingly clear, particularly based on the New York Times piece, that empowered patients alone won't be able to bend the cost curve. Despite the easy availability of information via the internet and self-diagnosis, there is value to the "expert" in determining the right course of action. As both Gladwell and Gawande note in their previous works there is a need for 10,000 hours of deliberate practice to become expert and that even the experts need coaching for continuous improvement, respectively.

The real problem is whether the "experts" are willing to make the judgement calls that our training provides? When to refer? When not to refer? When to get the MRI? When not to get the MRI? When to prescribe antibiotics? When to hold ground and sympathize when it is a virus? When to comfort, empathize, and heal when it means stopping chemotherapy when treatment is futile? When to do surgery? When to hold off? Are we willing to have others observe us in action so we can be even better? If not, why not?

For health care to be better, doctors must lead the change. No one else can. Insurers and employers have exhausted strategies to make patients more accountable.  Increasing deductibles and co-pays indefinitely won't work. Despite the unprecedented access to information, empowered patients and other patient advocates will never be able to fully close the knowledge gap. That difference in knowledge, as Gladwell points out in his book, Blink, is what allows an expert to distinguish between an authentic piece of artwork and a very good looking fake.

It is also the difference between stopping a number of unnecessary referrals and the cascade effect of subsequent imaging, blood work, and appointments and instead focusing on the patient.

Who will shape health care? Doctors, Patients, and Insurers and in that order.

Or entrepreneurs who partner with doctors to solve our challenges so we can go back to focusing on healing patients.

Will Doctors or Patients Bend the Cost Curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don't provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is - will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won't likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor's income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece "Do Patients Want More Care or Less"? 

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”... [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one "just to be safe?" Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn't necessary, how an individual's personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn't talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won't be the result of our professional organizations rolling out an educational component, or the media highlighting the "waste" in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the "father" of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,"

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

In the end, it will be doctors who can bend the cost curve.

Do Computers Really Come Between Doctors and Patients? Is the Future Here?

One of my favorite movies is Back to the Future starring Michael J. Fox.  I must admit after reading this New York Times piece, titled "When Computers Come Between Doctors and Patients" I have to wonder.

Am I fortunate to be coming from the future?  Because I completely disagree with Dr. Danielle Ofri, again.

I've had the privilege and opportunity to work in a medical group which has deployed the world's largest civilian electronic medical record and have been using it since the spring of 2006.  I don't see the issue quite as much as Dr. Ofri did.  It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can google any image instantly? Patient friendly information to reinforce our discussion is a click away.

The computer can certainly enhance the doctor patient visit. Like any skill, unless we deliberately practice in getting better, we will simply find the new method awkward and unnatural.

And the same goes for emailing patients securely.  An October 2010 article in Pediatrics found that for a 127 families only 5 emails were generated compared to over 2300 phone calls over an 8 month period.  The data doesn't lie.

The conclusion of the article was that -

Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.

So doctors could conclude that patients really don't want to email their doctor.  What a relief because the majority of patients still do not have the option to do so and doctors don't really want to do it.  (Though there could be compelling business reasons not to offer email to patients even if the doctors were technically savvy enough to offer it).

But yet this earlier press release in July 2010 may cause doctors to pause before returning to paper charts, pens, and phones.  This study found that over a two month period, 35,000 patients generated 556,000 email threads.

So what does this all mean?  As doctors we need to change our mindset and look at these changes as opportunities for the medical field to provide care that is increasingly worry-free, hassle-free, and personalized.

The future is here.  That means embracing the computer.

None of my patients would ever go back.

Neither would I.

Speaking of Back to the Future, I understand a limited supply of Marty McFly's shoes are now available for purchase!  Bids are at $4000!

NY Times - Finding a Quality Doctor - Why the Author and Doctors Are Wrong.

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes.  From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following - 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal.  She correctly notes that these measurements alone aren't what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor's bedside manner, should count as well. 

Her article was simply to illustrate that "most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care" yet when she offered this perspective, a contrary point of view, many viewed it as "evidence of arrogance."

She comforted herself by noting that those who criticized her were "mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care."

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card -

I don't even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It's too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them. 

As a practicing primary care doctor, I'm afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can't do both.  She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death.  They aren't in the office and yet are suffering.

Until we as doctors begin to take responsibility for our performance in hard clinical and objective outcomes like glycated hemoglobin levels, cholesterol, and blood pressure, our patients will pay a price.  We should not pretend that bedside manner should trump clinical outcomes nor that clinical outcomes should override the humanistic part of medicine.

It is possible to do both today.  It isn't theoretical.  I only serve as one example.


I'm a front-line primary care doctor who also takes care of patients. I like Dr. Ofri also get a report card on my performance in caring for patients with diabetes.

Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.

I suspect critics will immediately begin to make a lot of assumptions of how these scores were achieved, when Dr. Ofri, another primary care doctor had very different outcomes.  Is it that I am not a quality doctor? Perhaps I’m too driven by data and have no - “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication.  Perhaps I "fire" those patients who are not able to achieve good outcomes.

I can tell you many patients wish to join my practice and rarely do people choose to leave it.  The organization I work for also takes the softer side of medicine, a doctor’s bedside manner, seriously.  My employer randomly surveys patients on their experience. Does your doctor listen and explain? Do they know your medical history? Do they partner with you in your health? Do you have confidence in the care they provided you?

For 2010, 92.8 percent rated me very good or excellent on these elements.

So what does this all mean?

We should not automatically assume that doctors with great bedside manner cannot also provide great clinical care.

I can achieve the goals, which patients would want, and still be a doctor with great bedside manner because I work in a functional system like Kaiser Permanente. Primary care doctors are blessed with a comprehensive electronic medical record, are partnered with staff who help patients get the care they need, and are surrounded by specialty colleagues equally as focused to keep patients healthy and well.

So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes.  Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn't necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves.  Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.

Until we as doctors lead, we cannot or should not expect improvement in patient outcomes.  We can no longer hide behind the reasons of our Herculean effort or bedside manner as what should really matter and account for something.  Patients expect these attributes intuitively.

With already so many examples of success in the country marrying the art, science, and humanistic part of medicine, the only thing stopping us to re-invent American medicine in the 21st century is simply ourselves.

Newsweek - Just Say No! - One Word Can Save Your Life. Too Simplistic. Doctors Need to Help.

Newsweek has a very provocative and yet incredibly too simplistic piece for the public and patients on its cover story - One Word Can Save Your Life: No! - New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.

The piece is actually well written and highlights facts that have been apparent for some time.  More intervention and treatment isn't necessarily better.  Having a cardiac catheterization or open heart surgery for patients with stable heart disease and mild chest pain isn't better than diet, exercise, and the prescription medication treatment.  PSA, the blood test previously suggested by many professional organizations, isn't helpful to screen for prostate cancer, even though the value of the test was questioned years ago.  Antibiotics for sinus infection?  Usually not helpful.

Certainly doctors do bear part of the blame.  If patients are getting routine colonoscopies sooner than every 10 years or are getting them despite being quite a bit older (80 and older) and frail, then clearly patients should say no to more care.  More isn't better.  (Whether a patient has the conviction to do so is another story.  When my auto mechanic says it is time to change the brakes or change the oil, who am I to say no?)

But the overtreatment and overuse of medical technology does not just fall on the doctors.  It is also the patients' and the public's perception of what is the right care.  Whether this perception was shaped by doctors, the media, movies and television shows, or patients comparing notes is hard to say, but the reality is patients have a certain expectation of what should be done which often is in stark contrast to the right thing to do.  For low back pain, many patients simply want a MRI and avoid an examination or visit.  After all, isn't the truth in the MRI?  Isn't talking to a patient and examining his back, knee and ankle reflexes, evaluating for joint strength and sensation simply from a by-gone era that is antiquated in the 21st century?  Do patients know the limitations of our understanding not in the history or physical examination honed by generations of doctors before us, but the shiny new piece of technology rolled out annually by General Electric?  As Dr. Michael Lauer, a cardiologist of the National Heart, Lung, and Blood Institute noted in the piece, “Our imaging and diagnostic tests are so good, we can see things we couldn’t see before...But our ability to understand what we’re seeing and to know if we should intervene hasn’t kept up.”

Doctors who do provide the right care, which often is low tech and common sense, might be viewed as denying care.  If a patient has chest pain which is easily treated with a statin (cholesterol lowering) drug and beta-blocker and a cardiologist is not needed for further intervention, do you think the patient or the family will feel more relieved or more anxious?  If a stress test isn't offered to an otherwise healthy middle aged man as part of a physical (or at a minimum an EKG) and yet is offered the identical tests as part of an executive physical, do you think the public at large will feel better or worse in not having the tests, which are correctly noted in the article not proven to save lives?  (It is ironic that although fantastic experts are quoted in the piece including Dr. Steven Nissen, a cardiologist at Cleveland Clinic, his organization offers executive physicals, which you guessed it provide many of these tests and interventions to paying clients.  Though the results of the majority of the tests are normal it is that remote possibility that something might be wrong and the basis of the testimonials on the website that have the public clamoring for more testing and treatments).

In today's society where news is disseminated as sound bites or tweets, I am concerned about the unintended implications this Newsweek story will bring: patients will say no to everything.  Based on a well written, though not entirely balanced article, patients will anchor their decisions to default to no based on this small piece of information.  It has already occurred with vaccinations.  As the National Committee for Quality Assurance noted in its 2010 State of Health Care Quality report, childhood immunization rates for those in private insurance has actually fallen compared to those in public insurance (Medicaid) plans.

Childhood vaccination rates in 2009 declined by almost four percentage points in commercial plans.
   
A possible cause of this drop is commercial plan parents may refuse vaccines for their children based on the unproven, but increasingly popular, notion that vaccines cause autism. Celebrity activists are outspoken advocates of this view. Interestingly, we see vaccination rates in Medicaid – the program serving the poor – continuing to steadily improve.  

“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said NCQA President Margaret E. O’Kane. “All of us in health care need to work together to get better information to the public.”
The State of Health Care Quality Report examined quality data from over 1,000 health plans that collectively cover 118 million Americans.

Because of the complexity, nuances, and ever changing nature of medicine, patients more than ever need doctors to lead and be firm on what works and what does not.  The anecdotal quote by a doctor who opted not to have a mammogram should be taken as one person's opinion and not a recommendation for all women to do the same.  Having patients say no or expecting them to make the right decisions for themselves and family is not how the country will get better care.  A recent NY Times piece by Dr. Pauline Chen titled Letting Doctors Make Tough Decisions could not have been more timely.

... a new study reveals that too much physician restraint may not be all that good for the patient — and perhaps may even be unethical. While doctors might equate letting patients make their own decisions with respect, a large number of patients don’t see it that way. In fact, it appears that a majority of patients are being left to make decisions that they never wanted to in the first place….

The challenges appear to arise not when the medical choices are obvious, but when the best option for a patient is uncertain. In these situations, when doctors pass the burden of decision-making to a patient or family, it can exacerbate an already stressful situation. “If a physician with all of his or her clinical experience is feeling that much uncertainty,” Dr. Curlin said, “imagine what kind of serious anxiety and confusion the patient and family may be feeling.”

Medical choices are not as obvious.  Today the vast amount of information and choices are overwhelming.  The easy and natural thing to do is to run away or bury our heads in the sand, or simply say no when decisions are complex. 


The Newsweek article concludes -

Many doctors don’t seem to be getting the message about useless and harmful health care. Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help. Arthroscopic knee surgery for osteoarthritis is performed about 650,000 times a year; studies show that it, too, is no more effective than placebo treatment, yet taxpayers and private insurers pay for it. And although several large studies, including the Occluded Artery Trial in 2006, have shown that inserting a stent to prop open a blocked artery more than 24 hours after a heart attack does not improve survival rates or reduce the risk of another coronary compared with drugs alone, the practice continues at a rate of 100,000 such procedures a year, estimate researchers led by Dr. Judith Hochman, a cardiologist at New York University. “We’re killing more people than we’re saving with these procedures,” says UT’s Goodwin. “It’s as simple as that.”

Actually, I think doctors are getting the message as Dr. Atul Gawande noted in the June 2009, New Yorker piece Cost Conundrum.  Doctors are compensated more to do more.  Even medical students get the message.  Increasingly more are becoming specialists as reimbursement is far more lucrative in doing procedures than it is to simply talk and counsel patients.

The Newsweek piece tries to simplify the problem too easily by hinting to patients that saying no is a good thing rather than challenging patients to have an open-minded, important and thoughtful conversation about the advantages and disadvantages of having certain tests or treatments with their primary care doctor.  Of course since fewer medical students want to do primary care, my job and those of my colleagues in family medicine and internal medicine just got a lot harder.

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.

The Disappearing Family Doctor - Is It a Bad Thing?

The New York Times recently published an article titled the Family Can't Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and "doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat...larger practices tend to be less intimate"

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service.  How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing.  Of course, there was a price.  His life was focused solely around medicine which was the norm of his generation.  Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner.  Not surprising.  In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient.  This is bedside manner.  The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given?  My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary.  One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening.   Those most likely to do the wrong test after a positive stool screening test?  Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice. 

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care.  I've worked at Kaiser Permanente (KP) in Northern California since 2000, a "larger practice".  The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka's.  Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient's lab work, imaging studies, and medications 24/7.  Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices.  Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor's appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let's not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors' offices as automatically dooming doctor-patient relationships to becoming more impersonal.  The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them.  Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor.  To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all. 

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices.  It offers no evidence if the quality of care delivered is as good.  Let's not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing.  It may not be up to the challenges of the 21st century.

The Rise of Desktop Medicine -- Wrong Terminology, But Right Thing to Do

A recent NY Times article, the Rise of Desktop Medicine, highlighted the use of technology in accessing information (desktop medicine) and how doctors were spending less time with patients (bedside medicine).  Many doctors were concerned about the change and longed for the old days.  Yet, the reality is that with more medical knowledge, doctors must retrieve information from clinical trials, calculate risk of heart attack or osteoporosis, rather than rely on intuition, particularly when data exists.

My biggest problem with this article really was with the term desktop medicine.  I don't like it.  Certainly over the past few decades, our understanding of certain illnesses has become more precise, the interventions and treatments more clear, and therapies more evidence based (precision medicine).  Other illnesses, however, still continue to be more challenging and determining the correct course of action less clear (cognitive or intuitive medicine). 

Precision medicine, a term used by Harvard Business School Professor Clayton Christensen, has simply occurred at the same time computers and the ability to rapidly access information developed.  Imagine if medical science knowledge had evolved but that there was no infrastructure or technology available to retrieve information like clinical trial outcomes quickly.  Doctors would still be treating patients based on intuition rather than science completely oblivious to the latest knowledge.  Research has shown it takes 17 years before outcomes from research studies become commonly practiced in the community.

No desktop medicine isn't the right term to describe the phenomenon in medicine.  It implies doctors are simply indentured servants to computers and technology.  Nothing could be further from the truth.  Generations ago, doctors had few tools and treatments.  When people developed pneumonia, we could do nothing but wait and hope because antibiotics were not discovered yet.  We simply comforted individuals and families.  Many people died.

Today we have more tools, more treatments, and a better understanding of many, but not all illnesses.  To say this additional knowledge and the ability to retrieve this information somehow erodes the doctor patient relationship is incorrect.  We can still be caring and use our technology to access information to make the care of the patient in front of us more precise and personalized than ever before.

No, the terms desktop medicine and bedside medicine are incorrect because they provide the wrong type of connotation.  The former term implies cold and impersonal.  The latter term suggests humanity and comfort.  Better terms with less emotional attachment would be precision medicine and intuitive or cognitive medicine.

I'm a big fan of the art of medicine and bedside manner.   I also love how my computer allows me to make care more convenient and more personal. 

The next generation of doctors must be experts at both bedside manner and using the vast knowledge of medical science to make care precise in areas we have good understanding.  For illnesses where we don't, we still do what we did generations ago, comfort and heal. 

No computer will ever replace that.

Colon Cancer Screening Guidelines - Colonoscopy Better Than Sigmoidoscopy? The Truth and the Myth

Colon cancer screening has a particular personal interest for me.  One of my colleagues in residency training had her father die of colon cancer when she was a teenager.

No one should lose a love one to a disease when caught early is often treatable.  Although for both men and women, colon cancer is the third most common behind lung and prostate cancer in men and behind lung and breast cancer in women, it is the second most lethal.

The problem is that patients are often confused about which test is the right one.  Is it simply a stool test?  Flexible sigmoidoscopy?  Colonoscopy?  Virtual colonoscopy?  Isn't there just a blood test that can be done? (No.)

In real simple terms, this is all you need to know. 

All men and women age 50 and older should be screened for colon cancer.  Even if you feel healthy and well and have no family history, it must be done.  Note that Oprah's doctor, Dr. Oz, arguably a very health conscious individual learned that he had a colon polyp at age 50 after a screening test.  Left undetected, it could have cut his life short.  This wake-up call caused him to abort his original second season premier on weight loss and instead show the country why colon cancer screening matters.  He admitted that if it wasn't for the show and the need to demonstrate the importance of screening to America, he would have delayed having any test done.

The least invasive test is a stool test.  If it is to screen for colon cancer, then the test is done at home and NOT in the doctor's office.  Either the fecal occult blood (FOBT) or the fecal immunochemical test (FIT) are available to screen for unseen microscopic blood that could be a sign of a colon polyp or cancer.  Research shows that when done annually the risk of dying from colon cancer can fall by 15 to 33 percent.  If you don't want any fiber optic cameras in the rectum and lower colon, this is the test for you.  You must do it annually.

The next two tests are similar but often confused - the flexible sigmoidoscopy and the colonoscopy.

The flexible sigmoidoscopy examines the lower third of the colon, known as the sigmoid and the descending colon.  Patients cleanse the lower colon by ingesting a small amount of laxative the day before the procedure.  If a colon growth or polyp is found, it can be biopsied or completely removed during the procedure.  The test is typically done in 15 to 20 minutes.  Patients are awake for the procedure and can go home.  Research shows this test can decrease the number of deaths due to colon cancer.  The risk of the procedure is very small with about 1 in every 5,000 patients having a small tear or perforation.  This flexible sigmoidoscopy test is done every 5 years. 

Like the sigmoidoscopy, the colonoscopy also requires cleansing of colon, however, a gallon of laxative is require to empty the entire colon.  Colon growths and polyps can be removed similarly.  Unlike the sigmoidscopy, however, the colonoscopy requires that patients be sedated.  As a result, you will need someone to take you to the appointment and drive you home.  Although the procedure itself takes about 30 minutes, it can be a few hours from arriving to going home due to the anesthesia.  Out of all of the screening tests, it is the most risky with an estimated perforation rate and cause of serious bleeding affecting in 1 in 1,000 patients.  A colonoscopy is done every 10 years.

Would checking the entire colon with a colonoscopy be better than evaluating the lower third of the colon with a sigmoidoscopy?  Evidence that colonoscopies save lives from colon cancer is lacking.  This subtle but important point is often not mentioned in media reports.  Even the NY Times perpetuated this belief that colonoscopy is the preferred test in its January 20th, 2011 article, "Why People Aren't Screened for Colon Cancer."  When family medicine doctor and lecturer in health care policy at Harvard medical school, Dr. John Abramson, wrote a letter to the NY Times editor in February 15th, 2011, noting the this fact in an unrelated article, the American College of Gastroenterology (ACG) wrote a letter indicating that a colonoscopy is their preferred test for screening.

No wonder patients are confused.

If one dissects the ACG letter carefully, we note the following language (words bolded for emphasis):

American College of Gastroenterology’s 2009 colorectal cancer screening guidelines recommend colonoscopy as the preferred cancer prevention strategy, and guidelines by the American Society for Gastrointestinal Endoscopy in 2006 also endorse colonoscopy because of its ability to view the entire colon and remove potentially precancerous polyps, reflecting a strong opinion of these experts that prevention should be the primary goal of colorectal cancer screening.

While public health experts have recently debated the exact parameters to measure the impact of these screening strategies on mortality, a clinical picture that is muddied by the many variables affecting the quality of the examination, the jury is still out. Indeed colonoscopy’s protective power may lie in a growing appreciation that the biology of precancerous polyps and cancer is different in the right compared to the left colon.

In other words, the recommendation is based on opinion.  There is no language indicating that there is evidence.  The "protective power may lie" in such and such, but hasn't been confirmed.  Examples of when doctors made opinions when evidence was lacking only to change their minds later include hormone replacement after menopause, bone marrow transplant for breast cancer treatment, and prostate cancer screening with PSA.

A study that appeared in the Annals of Internal Medicine in the January 6th, 2009 issue, researchers found that colonoscopies did cut down colon cancer deaths, but it was due to detection of the left sided colon cancers (sigmoid and descending colon) and not to the right side, of which only the colonoscopy can reach.  In other words, a flexible sigmoidoscopy would have detected the cancers as well, which has been observed in previous studies. 

Researchers reviewed health records for persons aged 52 to 90 who received a colorectal cancer diagnosis between 1996 and 2001 and died of colorectal cancer by 2003. These patients were compared to a control group who were selected from the population of Ontario and had not died of colorectal cancer.

According to the researchers, complete colonoscopy was strongly associated with fewer deaths from left-sided colorectal cancer. Conversely, the data showed that colonoscopy seemed to have almost no mortality prevention benefit for right-sided colorectal cancer.

So who do you listen to?  I typically review the guidelines from the American Cancer Society (ACS).  As a group advocating cancer screening and awareness, they should have no bias about what test to use to screen for colon cancer.  For individuals at average risk for colon cancer, ACS notes that to find colon polyps or cancer, either a sigmoidoscopy every 5 years or colonoscopy every 10 years.  Their recommendations don't say the preferred option is a colonoscopy.  The Centers for Disease Control the US Preventive Services Task Force, and the National Cancer Institute also say little about which is preferred. 

What does this mean to you?  For those at average risk and no family history of colon cancer, get screened for colon cancer at age 50.  At the bare minimum, do an annual stool test if you don't want an invasive procedure.  Know that at this time there is no evidence that colonoscopy is better than a flexible sigmoidscopy.

If people tell you otherwise ask them to show you the evidence.
And let me know.

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.

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.