Your Medical Mind - Book Review. Best for Patients or Doctors?

I looked forward to reading Dr. Jerome Groopman’s new book, Your Medical Mind: How to Decide What Is Right for You , co-authored with Dr. Pamela Hartzband.  His previous work, How Doctors Think , shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions.  I always recommend my medical students read that book.

Unfortunately, his latest work fell quite short of my expectations.  In it, the authors try to understand and create a framework on how patients reach decisions about their medical care.   In the end, this was a book about human psychology wrapped in the doctor patient relationship.  Nothing particularly earth shattering here.

The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors?  Patients or doctors?

They note how the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.”  Specifically, some patients want maximal treatment and others believe “less is more”.  To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms.  Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.

Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions.  Finding a doctor who provides “shared medical decision making” might also decrease the chance of making a choice only to regret it later.  In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament.  Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference.  There is both power and potential pitfall in hearing other patient’s stories, which may be anecdotal.

Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance.  Sometimes patients want full control.  Other times they wish to cede it to physicians, hence the reason many want to find the “best” physician.  Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use “substituted judgment” and choose treatment based on what the patient would have wanted.  Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation.  As a result, sometimes doctors use the principles of “beneficence”, the principle that physicians should act in the patient’s best interest, and “nonmaleficence”, to do no harm.

Physicians can also unwittingly bias a patient’s decision by recommending a “best” treatment and downplaying others, which could be a better match for the patient’s preference.  Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient.  These seems rather ludicrous as already many current guidelines are not being followed.

The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don’t simply rubberstamp what you want.  “A doctor who facilitates but also may challenge your decision process sometimes gives you more.”

Completely agree. Perhaps this book is best suited for doctors.  While the book may be an enlightening read for patients, there isn’t necessarily an easy practical framework which will help them make the right decisions.  

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!

A Doctor Thanks His Mentor - Steve Jobs

I've been reading A Game Plan for Life: The Power of Mentoring written by famed UCLA basketball coach John Wooden.  Wooden spends half of his book thanking the people who had a powerful influence on his life, coaching, philosophy, and outlook on life.  Important people included his father, coaches, President Abraham Lincoln, and Mother Theresa.

Yes, President Abraham Lincoln and Mother Theresa.

Though clearly he could have never met the former and didn't have the opportunity to meet the latter, Wooden correctly points out that as individuals we can be mentored by the writings, words, and thoughts of people we have never and will likely never meet.

Which seems like the most opportune time to thank one of my mentors, founder and former CEO of Apple, Steve Jobs.

Now, I have never met nor will I ever meet Steve Jobs.  Lest you think I'm a devoted Apple fan, I never bought anything from Apple until the spring of 2010.  Their products though beautifully designed were always too expensive.  I'm just a little too frugal.  I know technology well enough that people mistaken me for actually knowing what to do when a computer freezes or crashes.  Yet, the value proposition was never compelling enough until the release of the first generation iPad.  Then the iPhone 4.  Finally the Macbook Air last Christmas.

No, thanking Steve Jobs isn't about the amazing magical products that have changed my life as well as millions of others.  It's more than that.  What he has mentored me on is vision, perspective, persistence, and leadership.  Nowhere is this more important than the world I operate in, the world of medicine.  Increasingly health care is fragmented, confusing, and frustrating for patients.  As Dr. Atul Gawande noted in his commencement to Harvard Medical School:

Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.

We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people.

We don't have an actual system of care.  A majority of doctors still use paper charts and prescription pads which can be difficult to access or decipher (doctors have poor penmanship?) and communicate with colleagues via letters, faxes, and phone calls.  In an industry which is information driven, this seems too antiquated to be true.  Hospitals each have their own unique system of care and their is little standardization which means both patients and doctors need to learn new rules with each new hospital.  Patients cannot invest in long term relationships with their doctors because they change jobs, their company or their doctors dropped their previous insurance plan.

What we have is a potpourri of doctors, hospitals, pharmacies, and health insurers cobbled together to form a "health care system".  For a patient, the number of combinations is staggering.  Each experience varies depending on who they see, what insurance coverage they have, and the type of (or lack of) information technology their doctors have.  Many doctors today still bristle at the possibility that they actually need to email their patients and as a result don't offer that as a way of communication or education.

In the end, what patients and doctors really want sits at the intersection of humanity and technology.  Patients want doctors who know them as individuals, use medical technology thoughtfully, and a system that is highly reliable, safe, and focused on them to stay well or get them better.  Doctors want patients who are partners in their care, technology that enables them to get the accurate information they need real-time, and a system that is streamlined to allow doctors to be healers.

In other words, we need a better health care system for both parties.

As a practicing primary care doctor, his words inspire me to help work towards creating a system which "simply works" for both doctors and patients.  Some of the most important quotes that has shaped my thinking include:

“Innovation has nothing to do with how many R&D dollars you have. When Apple came up with the Mac, IBM was spending at least 100 times more on R&D. It’s not about money. It’s about the people you have, how you’re led, and how much you get it.”
— Fortune, Nov. 9, 1998

“It’s really hard to design products by focus groups. A lot of times, people don’t know what they want until you show it to them.”
— BusinessWeek, May 25 1998

“It comes from saying no to 1,000 things to make sure we don’t get on the wrong track or try to do too much.”
— BusinessWeek Online, Oct. 12, 2004

“Do you want to spend the rest of your life selling sugared water or do you want a chance to change the world?”
— The line he used to lure John Sculley as Apple’s CEO, according to Odyssey: Pepsi to Apple, by John Sculley and John Byrne

"So you can't go out and ask people, you know, what the next big [thing.] There's a great quote by Henry Ford, right? He said, 'If I'd have asked my customers what they wanted, they would have told me "A faster horse." ' " -- CNN / Money

"My job is to not be easy on people. My job is to make them better. My job is to pull things together from different parts of the company and clear the ways and get the resources for the key projects. And to take these great people we have and to push them and make them even better, coming up with more aggressive visions of how it could be." -- CNN / Money

"Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary." -- Stanford 2005 commencement address

Many of my blog posts have reflected on whether health care can indeed be better than it currently exists much the same way Jobs has redefined how we as a society communicate, relate, receive, and create content.

Does America Want Apple or Android for Health Care? 

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

Why Healthcare Needs to be More Like Apple and Less Like Windows / Intel 

I as a doctor I'm incredibly sorry that medicine has not yet evolved to the point that a cure exists for the rare type of cancer Jobs.  I'm sorry that he is so ill at an incredibly young age, in his mid 50s, when many people begin to contribute even more to society with all of the knowledge and experience they've acquired.  The future might be a little less bright without Jobs leading his team at Apple on creating products and experiences none of us truly knew existed until he showed them to us.

And yet, I wanted to thank him for his mentoring.  Clearly though the outpouring of comments and support across the web, Steve Jobs has had a profound influence in many of our lives.  In most cases, it wasn't even about the products.

It was simply a way of living and viewing life.

I look forward to learning one last time from my mentor this fall with the release of his book titled Steve Jobs. 

My thoughts are with him, his family, and the people at Apple who continue to innovate and challenge themselves so the rest of us benefit.

What Doctors Wish Their Patients Knew - Critique of the March 2011 Consumer Reports article

First, I'm a big fan of Consumer Reports and even listed their Consumer Reports Best Buy Drugs website in my book, Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System, because of its accurate, unbiased, and money saving information in getting the right treatments for the best price.

So naturally when I saw this month's issues cover story - What Doctors Wish Their Patients Knew, I had to read it.  Overall, it was excellent and made a lot of sense.   Their conclusions were obvious to me, however, might not be as intuitive to the public (after all it is titled what doctors wish their patients knew!).

In summary, primary care doctors matter and having a long-term relationship with one can save time and money.  Respect and being courteous still matter to both doctors and patients.  Thoughtful use of the internet might overcome the resistance doctors have to patients researching information.  Generic medications, which are inexpensive and very effective for many conditions, are excellent and should be used.

A more in depth analysis reveals the following.  Primary care doctors are vitally important.  As Dr. Kevin Grumbach, professor and chair of the department of family and community medicine at the University of California San Francisco noted, "a primary-care doctor should be your partner in your overall health, not just someone you go to for minor problems or a referral to specialty care."  Indeed, that is why I went into primary care.  I prevent problems.  I diagnose problems.  On the occasion I can't solve your problem, then I need the assistance of my specialty colleagues.

I'm not a gatekeeper.  I'm not simply a referral center or an obstacle in getting you the right care.  In fact, I'm the first logical place to always get care and be your partner in keeping you healthy and well.

A long-term relationship with a primary care doctor is also important according to three-quarters of the 660 primary care doctors surveyed.  Consumer Reports found some evidence that patients who frequently switch doctors have more health problems and spend more on care.  This seems to make sense.  Having someone you know and trust to get care over a long period of time can keep you healthy and save you money.  The challenge for many Americans is trying to keep the same doctor.  Employers often switch insurance carriers to save money.  Doctors drop out of health plans.  Patients change jobs and have a different health plan or no health insurance coverage.  In other words, a primary care doctor isn't simply a commodity, but rather a vitally important relationship.  Unfortunately the health care system and the general public don't view them that way.  Practicing primary care doctors are leaving the specialty and medical students are not interested in a primary care field even though it is has potential to be one of the best choices in the future.

Respect and being courteous are two traits still valued by doctors and patients.  The majority of doctors polled felt that being respectful and courteous would help get better care.  Patients equated respect and courteousness as professionalism.  Doctors who treated them respectfully, listened to them with understanding, and spent time with them scored high.  Though professionalism scores increased more when patients felt that their doctor seemed technically competent, I find it hard to believe that patients can honestly determine who is skilled clinically.  I think my car mechanic is skilled, but I really don't truly know as I'm not a mechanic.

I'm sure patients believe I'm technically competent as I explain everything I'm doing.  For a knee examination, patients will hear me say -  I'm palpating the meniscus both the medial and lateral aspects to check for arthritis or a meniscus tear.  I'm examining the medial and lateral collateral ligaments of your knee and making sure they are intact and not strained or torn.  I'm looking for fluid in the knee and mechanics of the knee with the range of motion.  I'm checking the health and integrity of the ACL and PCL.  Instead of wondering if I'm simply waving my hands like a magician, the description of the examination demonstrates my value as a doctor.  Patients, and some doctors, have forgotten the value of taking a detailed history and a good physical examination.  There was a time doctors didn't have the imaging tests of xray, CT, or MRI.  Once I explain what I'm doing, then they understand why these tests are often unnecessary, which of course saves money and time. If showing and verbalizing our examination and thought process is professionalism, then we need to do more of it.

Although the article suggested that 80 percent of doctors felt taking a friend or relative to an office visit would be helpful, I believe this expectation to be a little unrealistic.  Unless a family member or relative is particularly worried or if the visit is very important, say a consultation with a surgeon or an oncologist, it isn't necessary to have someone else tag along.  People are incredibly busy.  Taking time out of the day to accompany someone for an appointment isn't going to happen.  The reason for this suggestion is that doctors discover patients don't typically remember everything that occurred in the office.  This point really is about providing patients a strategy to recall important information (using the mneumonic D.A.T.E. can be helpful).  

Suggestions on how to thoughtfully research information on the internet was a plus.  Besides MedlinePlus and the Mayo Clinic, one should also consider Healthcare.gov, which has a preventive app, my health finder, that gives personalized specific age and gender information on what tests are needed and appropriate (it's under the Learn About Prevention tab).  Not surprisingly due to the ease of looking information on the internet, 61 percent of patients have researched their condition.  Sadly doctors were not as enthusiastic.  Half of doctors said that online research was not helpful at all.

Physician wariness to the plethora of online information is due to the lack of respect from some patients who demand certain treatments, medications, or interventions, without understanding the nuance of a diagnosis.  It isn't as simple, though it seems like it, as putting in a bunch of diagnoses and then just then hitting Google search (or worse I'm feeling lucky).  I don't mind patients emailing me links to articles or suggest diagnoses.  In fact, I learn a lot from patients.  I do however find it difficult to treat patients who are insistent on their way or the highway and in those cases will suggest they find another doctor.  It's about a trusting partnership not just about patients who are empowered with small pieces of information.

Finally, the best part of the issue was he Best Buy Drugs section which notes that many conditions, like high cholesterol, diabetes, heartburn, allergies, and depression have very good generic prescription medications that are inexpensive and very effective.  Consumer Reports uses evidence based research to back up the claims.  The vast majority of patients I care for do fine with generic medications.  That's what I buy.  You should do fine with generic medicationas as well.  They left out my favorite online pharmacy, Healthwarehouse.com which often has pricing better than Wal-mart and Costco for many medications.

What else do doctors wish patients knew?  Vaccines are safe and underutilized.  Body scans and life line screenings really aren't worth your money.  The fountain of youth really is eating less, moving more, and not smoking, and plenty of servings of fruits and vegetables.  Cancer screening tests are for everyone, not those with family histories as the majority of people who develop cancer are the first in their family.

But of course, that might take more than just a blog post, but an entire book.

Patients Lie. Why Doctors Should be Like Medical Students. A Good History is a Checklist.

The most common question first year medical students ask me is how do they become efficient at taking a patient history.  Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?  When can they stop asking about the review of systems, a list of questions asked about each organ system?  A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.


Patients lie and don't even know it.  It's not that they mean to.  In fact, they are trying to be helpful when giving a history of their symptoms.  Medical students concerns about taking a fast history reflects two things.  First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past.  Second, more importantly, is their fascination and desire to get started on real medicine -- what are the diagnoses, treatments, and tests that must be learned to be a good doctor.


In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening.  Taking a good history is the essential part of being a good doctor.


Here are two examples of patients who I saw during the winter.  The practice is busy this time of year.  I'm often running late.  Like many encounters, I've never met these patients before.  In many ways, it can feel like an urgent care practice.  Which patient is lying?  Can you tell?

Young woman wanting a work note for the flu.  She was complaining of a three day history of diffuse muscle pains, headache and high fever.  That's it.  She had no other concerns.  Just anxious to get home and go to bed.


OR


A young man with an ankle injury after playing soccer.  As an aside, he also asked about stomach flu which occurred a few days prior.  He had nausea, abdominal pain, and vomiting for a day.  He still had abdominal pain.

Which one was lying?  Both.

A medical student or doctor recently out of training might have not missed the diagnosis in either patient because they are still working on how to hone down their questioning.  In other words, they haven't take the shortcuts yet and still ask comprehensive histories.  Yet, they aspire to just ask the vital questions to be efficient.  A more seasoned doctor who is stressed and busy may have taken mental shortcuts and moved on.

In other words, how do you know what is and isn't vital until you ask?

Patients also have fallen into this trap believing this tradition of talking to their doctors is simply unnecessary, worthless, and an obstacle to getting to the truth.  With increasing out of pockets costs for office visits, I'm seeing more requests from patients to simply get a MRI or blood test instead of seeing a doctor not only to address the problem, the real reason for the tests, but also if testing is usually necessary (it isn't in the vast majority of cases).

A good history is very much like the checklists pilots use and what Dr. Atul Gawande advocates in his book.  Taking a good history also slows doctors down and allows them to avoid cognitive errors (as described beautifully in the book How Doctors Think), think more clearly, and avoid jumping to premature conclusions.  Even the time honored skill of thinking through a differential diagnosis and thinking hard to make a long list of possibilities is a checklist and safeguard to consider other alternative problems that wouldn't appear when stressed.   Being a doctor requires thinking and less knee jerk responses. 

So what did the two patients have?

The first patient didn't have the flu.  She had a kidney infection known as pyelonephritis.  In taking the review of systems when asked about her urination pattern, she realized that it had changed during her illness.  Also, in asking questions, she had no other signs of having a upper respiratory illness, no cough, no runny nose, no head congestion.  Instead of simply writing a work note for a presumed virus and moving on to the next patient, this patient received antibiotics.  Untreated, pyelonephritis can be serious and require IV antibiotics or hospitalization.


The second patient didn't have stomach flu.  In fact, patients also make similar mental shortcuts by telling us what they think is going on - "stomach flu" rather than telling us specific systems.  When people refer to stomach flu, like food poisoning, often there is nausea and vomiting which then is followed by diarrhea.  He didn't have diarrhea just persistent abdominal pain.

He had gastritis, irritation of the stomach lining, due to alcohol abuse. Asking about his social history, he admitted to binging on a 12 pack of beers that day, a behavior, not uncommon for him.  Not only was he treated for this, he was also recommended to quit drinking.

So even experienced doctors can take a page from medical students.  It's the taking the history that matters.  Everything else we do, the physical exam, lab work, and imaging tests are tools and not the truth.

Want to know, one other time a patient lies?

When you see an otherwise healthy young man in the office who simply wants an annual check-up just to be safe.  These types of patients are as common as seeing the Loch Ness monster.

The real reason he's there?  His spouse, girlfriend, or significant other for a symptom he's been complaining about but didn't want to see a doctor.

If I don't get to that truth, guess who I'll be seeing next week?  The same patient again but with his spouse, girlfriend, or significant other.


Or he's asking about Viagra.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why Medical Students Should Choose Primary Care - Not for the Reasons You Think

The current generation of medical students are not choosing primary care and instead are flocking to specialty care medicine in droves. Unlike decades ago when the best and brightest often went into internal medicine, the vast majority of students opt for dermatology, radiology, anesthesiology, and ophthalmology. Reasons for doing so include better predictable schedules, work-life balance, and compensation.

While I understand that proponents for more primary care doctors use other reasons to increase the primary care workforce, namely decrease the healthcare cost curve and improve health outcomes, medical students today need more compelling and practical reasons to do primary care.

I'll give three. Information technology / primary care transformation, globalization, and payment reform.

Before delving into the reasons, we must address why primary care is so unattractive to medical students. It isn't because of the relatively low pay of primary care doctors receive compared to other specialties and the high medical student debt that studies often suggest. The real reason is as primary care currently exists there is no sustainable work-life balance. Among gen X and the millenials, their identities isn't defined by their career. Unlike their baby boomer parents who lived and breathed their jobs, the newest doctors have other things to do in life.

This is why becoming a family doctor or internist isn't appealing. During their third and fourth years, students do clerkships or clinical rotations in all fields of medicine, including primary care. They experience first hand the daily struggles current primary care doctors have in administrative hassles, difficulty in care coordination in a paper chart world, decreasing reimbursement, and challenges accessing accurate real-time medical, prescription, and laboratory information. These headaches coupled with the intellectual need to be knowledgeable about a variety of aliments and problems seems too difficult to be a lifelong career.

This is true, if they were practicing today. However, by the time they finish training the world will already being shifting. When they retire thirty years later, primary care will have once again become the desired specialty of choice. Today's medical students are thinking a lot like the executives at General Motors; they are looking to the past - gas powered bigger trucks and SUVs. They should be thinking more like Toyota - hybrid or electric smaller vehicles.
The question medical students today need to ask is, where do they wish to place their bets?

They are extrapolating the future world based on their past experiences rather than envisioning the future.

If all they experience in their junior and senior year is the hurried, stressed, primary care doctor buried under paperwork, missing charts and lab results, and hurdles in communications and handoffs to other doctors then it makes why they choose dermatology, radiology, anethesiology, and ophthalmology.

But the primary care of today already looks very different for some doctors in this country and will be fundamentally different in a decade. As a result, the work-life balance problem actually is a non-issue. Those who choose specialty care will, in the future, be looking for jobs or taking pay cuts to live in especially desirable places.

Here's how the future is already taking shape.

Information Technology / Primary Care Transformation
For those individuals who have an entrepreunial spirits, groups like the Ideal Medical Practice, headed by L Gordon Moore, and Hello Health, lead by Jay Parkinson, allow doctors to practice true primary care. Both concepts focus on the doctor-patient relationship by getting off the fee for service treadmill which values patient volume and medical procedures. Since primary care medicine is a cognitive specialty requiring thought which take time and does not have the procedures that a cardiologist or gastroenterologist has, these doctors can only make a reasonable living by seeing more patients per day.

The Ideal Medical Practice (IMP) gets off the fee for service treadmill by slashing overhead cost dramatically by reducing ancillary staff and other fixed costs like office space to a minimum. Therefore the amount needed to cover the costs is less. As a result, one does not need to see as many patients as before to maintain a practice.

Hello Health works by having patients pay a monthly membership fee as well as direct payment when seen in the office. They generally don't work with insurers but instead get their payments directly from you. The benefit, however, is with the membership fee you can communicate with your doctor online via email or webchat like Skype. If you need to be seen it is often same day. The monthly fees that patients pay for these conveniences pays for the doctor's salary, as a result like IMP, the primary care doctor can spend time with you to figure out how to keep you healthy or get you better sooner.

Medical students however who don't wish to start their own practice can find competitive salaried positions at Kaiser Permanente, Geisinger, and other integrated healthcare delivery systems, as well as other private medical groups in communities that are thriving. Primary care doctors work hard, but enjoy their job, are paid a reasonable amount, and aren't planning on quitting anytime soon.

The experience above already exist today, but only exist in the minority of primary care practices. What they all have in common is the elaborate use of information technology, specifically electronic medical records, a can-do spirit on doing things far differently that what is currently experienced and observed by medical students in their clerkships in primary care, a relentless approach to managing expenses and overhead, and the mindset to always change. As a result, doctors are less stuck on the adminstrative hassles, less frustation on inadequate and often dated medical information, and are able to spend more time on valuable elements they enjoy in primary care, namely fostering the doctor-patient relationship.

As all successful healthcare organizations and systems know, the best infrastructure to deliver high quality medical care at the least cost requires a robust backbone of primary care doctors. With the healthcare crisis in the United States, primary care workforce shortage will be a priority. As primary care doctors embrace, and need to embrace, the technological innovations as well as the business practices, in the cases of those entrepreuners, primary care doctors ability to have reasonable compensation and work-life balance will be secured.

Globalization
So why are all of these medical students going en masse into specialty care doomed? It's not to say that the United States doesn't need specialists, but do we need as many? The reasons are globalization and new medical advances.

In terms of globalization, other doctors in other countries can do the same level of care for less. Currently elective surgeries like joint replacements and heart bypass can be done at 1/6 the cost in America if performed overseas in foreign hospitals by US trained doctors. Patients report experiences better than what they receive here. The outcomes are comparable. Some employers and insurers in the US send patients overseas, cover travel for themselves and a family member, as well as a small fee to do it. While the numbers are small, patients are willing to go.

With the digitization of radiology imaging and the creation of the internet, MRI and CT images can be sent quickly not only to hospitals but overseas. Radiology costs is about 1/3 the cost and images are being read by doctors in India, Austrialia. While US radiologists relish the fact that they no longer need to take night call for late night emergency room CT scans, they should also worry as should medical students contemplating a career in radiology.

It is only a matter of time, unless US doctors wish to take dramatic paycuts to match the pay of doctors in places like Thailand and India, that many elective surgeries and routine imaging reports are outsourced. Don't believe me? Ask the United Auto Workers or other cities and towns built on manufacturing and factories. They couldn't compete with Mexico or China.

In terms of medical technology disrupting specialty care, one only need to look at cardiothoracic surgery. The number of bypass surgeries for heart disease have fallen since the advent of cardiac stents. The number of cardiac stents done can be lowered with the improved focus on cholesterol management with statin drugs and blood pressure control. In other words, patients can avoid having any surgery done much more than even a decade ago as better medications and understanding of illness has occurred.

Who will manage these new medications and keep people healthy? Primary care doctors.

When laser eye surgery for vision correction started years ago, it required the expertise of a highly skilled ophthamologist. Cost for the procedure was thousands of dollars. Today computer assisted laser machines do the bulk of the work. Cost of the procedure now? Few hundred dollars.

As an overwhelming number of students go into specialty care, simple supply and demand coupled with the expensive elective procedures (and most lucrative procedures) being done overseas, and as medical technology continues to get better, specialists will have no choice but to take paycuts or move to areas perhaps less desirable to make a living.

Payment Reform
While primary care doctors current suffer under the fee for service reimbursement system, it is clear that the United States cannot continue to do so indefinitely. One need to look no farther than Massachusetts, which a few years ago was the first state to have universal coverage for all of its inhabitants. The state failed to address payment reform. As a result, and not surprisingly, costs continue to escalate with no demonstrable improvement in quality.

To address the budget gap, a state commission proposed changing the payment system to one that favors keeping the patient healthy, preventive interventions, and primary care by paying a monthly or annual fee. Insurer Blue Cross and Blue Shield has done just that in an experiment.
As a result, the incentive to increase volume or procedures is diminished and doctors are focused on delivering the most cost effective care.

So students going into primary care should take heart. You are choosing the right specialty for the future. To avoid the traps that your mentors have fallen into, be very picky about where you practice. Want to be your own boss? Want to be an employee? Either is fine. Make sure however that you work at a place dedicated to using electronic medical records not only for charting, but ordering and reviewing medications, lab results, and imaging. Check to see that your compensation isn't significantly died in to the fee for service service treadmill.

Then be thankful you made the right choice. There is no more rewarding experience than having a long relationship with another person which typically only comes by being either an internist or family doctor.

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.

Why healthcare needs to be more like Apple and less like Windows / Intel

There is a common perception in our country that more is better, particularly when it comes with choice. More choice means more competition and the ultimate beneficiary is the consumer. Is this actually true? Can there be too much choice?

Take consumer electronics, specifically, portable music players also known as MP3 players. Various hardware companies produced them with varying options and memory capabilities. Another companies had the music content that needed to be compatible with the variety of MP3 players. In addition, the MP3 players and the content providers needed to also be compatible with the large number of computer configurations offered by even more companies.

Although the enormous choice of MP3 players, content providers, and computer configurations allowed each separate category to be priced optimally due to competition, the irony was that very few consumers took the plunge of enjoying their music libraries on portable MP3 players. Too many problems occurred. Crashing the computer was probably the most common and frustrating. Many MP3 players had plenty of options, perhaps too many while others had too few. Music content providers worked like cable companies charging monthly fees which people frankly balked at because the content wasn't broad enough. In short, too many options caused confusion, the setup caused frustration, and consequently the promise of the digital revolution was just that, a promise.

Indeed when Apple introduced its iPod music player many years ago in 2001, Apple was a late entrant in the MP3 player market.

But it didn't matter. Millions have been sold. At Apple's recent conference, they noted that iPod's marketshare is at nearly 75 percent of the MP3 market and perhaps even more fascinating is that over 50 percent of purchasers have NEVER purchased an iPod before. In other words, iPod is entering households that normally wouldn't have a need for a MP3 player, let alone an Apple product.

Apple's success speaks volumes about what people really want. It isn't about choice, choice, choice, its about asking a simple question, what do people want? For Steve Jobs and his team, the question has been that simple, yet as complex. They determined that it was to have an intuitive MP3 player and seemless integration with content providers so that people could focus on the music experience and less on the technical aspects.

In many ways, this mirrors the original thinking with Macintosh computers, where the question was what do people want from their computers? It wasn't that they wished to type commands in DOS, but use intuitive interfaces and inputs like an icon based system and interacting with it using a mouse (and now touch screen with the iPhone and iPod touch).

The introduction of the iPod was a radical departure what people had previously experienced with MP3 players and other content providers. Both the interface on the iPod and iTunes, Apple's content provider of music, audiobooks, and then later video content which includes movies and television shows, were and still are elegant and simple to use. Both iPod and iTunes continue to have further improvements. Apple recently introduced iTunes version 9 and now offers iPods in a number of configurations including iPod Touch with WiFi capability and larger screen, the new iPod Nano, a much smaller device with a smaller screen as well as a built in video camera, and the iPod classic, which has a larger memory capacity, but looks like the original iPod.

So why was Apple so successful, when other companies presumably had an advantage by being first to market? Unlike the Windows / Intel configuration where different companies produce the software and others produce the hardware, Apple is a true vertically integrated consumer electronic company. Apple designs and produces BOTH the hardware and the software. Apple products work in a closed proprietary system. Apple's original iPod came in one color, white, and one configuration. The iPod essentially works with one system, iTunes. Fortunately, iPod and iTunes works with PC computers so the rest of the world can enjoy the benefits of thoughtful Apple engineering since only 5 percent of the PC market is currently held by Apple.

Apple won in the MP3 marketplace and is making significant headway in the smartphone market with its iPhone because the company continually asks an important question - what do people want?

So, in healthcare what do people really want?

Do they want choice, choice, choice? Do they want to have every test, every medication, every imaging test, every hospital, and every doctor available to them? Do they simply want the right test, the right medication, the right imaging test, the right hospital, and the right doctor available to help them get better?

Unfortunately, Americans believe in the former. Indeed, that is what economists would argue that more choices are better for everyone. Yet in the complex world of healthcare, can consumers get the correct combination of tests, medications, imaging tests, hospitals, and doctors to get the best outcome? It makes the simple task of hooking up a MP3 player to one's personal computer seem infinitely easier, yet history shows that until the introduction of Apple's iPod that acceptance was limited to those in the know, specifically technophiles.

Apple demonstrated with its iPod and iTunes that sometimes a simple streamlined system is far better than the chaos inherent in too many choices.

In healthcare, those in the know are doctors and patients who are fully engaged in being empowered, not because they want to, but because they have to, often because of a serious illness. Otherwise for the majority of us, we don't give much thought to our health until something happens. By then it is a hard learning experience of copays, deductibles, explanation of benefits, and network and out of network discussions. The vast majority don't want this responsibilty any more than they want to be technophiles in getting a simple MP3 player hooked up to their computers. There is nothing wrong with that belief. When people get ill they should be focused on simply getting better.

If we believe that this is what people really want, then what the American healthcare system needs instead of its fragmented configurations of multiple small medical groups, multiple hospitals, multiple radiology centers, surgery centers, and duplicity of medications, many of which are not better than existing therapies, and make itself more simple and user friendly. All patients would have a primary care doctor that they could rely on should something happen. This doctor would be one working in a large multispecialty group where primary care doctors and specialists work with specific hospitals with all of the imaging and operating rooms, and robust medication formularies with just the right number of therapies needed to do one thing - get the person they are treating better.

In other words, move from the world of Windows / Intel where more groups are available but do their own thing into the world of Apple where all of the players are aligned in the same direction. In healthcare, this means do what Apple does and use integration either true vertical or virtual integration to have the desired outcome.

Would the public stand for this or complain that their choices and their freedoms are being restricted?

Steve Jobs and his team at Apple know what people want in their world of consumer electronics. With his recent liver transplant, I wonder if he ever gives much thought on how to revolutionize the healthcare system?

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.

Do Doctors Have Time to Be Empathetic?

“But I also did not want to open the floodgates of emotion on an afternoon when the waiting room was overflowing. ”

One of the statements by Dr. Pauline Chen in her new column Doctor and Patient in the NY Times. The inspiration for the article was from a recent piece in the Annals of Internal Medicine which found that doctors missed the chance to give an empathetic statement the vast majority of time.

What Dr. Chen illustrates with her comment is the fear that the vast majority of doctors have and that is by being compassionate and empathetic that not only will it take too much time, but frankly is too uncomfortable for doctors to dare open the door. The reality is it doesn’t take much time and in fact may take less time. As Dr. Chen notes, when patients don’t get the feeling of a connection, they unconsciously fill this void some other way and lengthen the visit.

The issue isn’t whether doctors have enough time to be empathetic, which was suggested as the reason for doctors to miss 90 percent of the opportunities to provide a empathetic comment. The issue is whether medical students are trained adequately to be compassionate and thoughtful doctors.

It’s our training that fails us. It’s not the clock. The good news is like all other skills we developed in medical school, all doctors have the potential of becoming more empathetic with some simple behavioral interventions.

Until we as a profession realize that, it is no wonder patients feel increasingly alone when they access the healthcare system.