The Best Book on Healthcare Reform (or Surviving It)

The best book on healthcare reform or surviving it is The Innovator's Prescription: A Disruptive Solution for Health Care .  The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors, respected Harvard Business School (HBS) professor Clayton Christensen, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School Jerome Grossman, and another doctor and graduate of the MBA program at HBS Jason Hwang avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it.  They authors have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Elizabeth Edwards, Breast Cancer, and Mammograms - Her Death a Failure of Healthcare System.

Elizabeth Edwards died recently of breast cancer at 61, leaving behind three children, Cate (28), Emma Claire (12), and Jack (10).  Described by her eldest daughter as intelligent, humorous, and witty, I'm fairly certain that she would not have wanted to leave her children at such a young age. Yet, in November 2004, shortly after the presidential election, she announced to the public that she had discovered a breast lump, which ultimately was diagnosed as cancer.  She admitted shortly after her diagnosis that at age 55 that she had not been screened for breast cancer with a mammogram for about four years.

Which is why the recent report from the San Antonio Breast Cancer Symposium, done annually in December, is particularly worrisome.  The study period between 2006 to 2009 found these screening rates to be lower rates than the past.  Only 50 percent of women eligible to be screened for breast cancer actually did so.  That number improved slightly to 60 percent with women receiving two mammograms over a four year period.

In other words, 40 percent of women, who should get mammograms, aren't getting them.  

Just like Elizabeth Edwards.

Is it personal choice?  A cost issue?  Or lack of time?  Lack of understanding?  While experts debate, I'll tell you.

It's a lack of time and lack of understanding.  Everyone is incredibly busy.  Given a choice, patients will do the right thing if they are nudged to do so.  In fact, they want doctors to help guide them to the correct choice.  Elizabeth Edwards certainly as a mother and professional woman had the financial resources and intelligence to know the importance of annual mammograms starting at age 40, yet didn't do so.  Perhaps she didn't think she was at risk.  Maybe she was focused on her children and husband and didn't care for herself as much as she should have, a common trait for many mothers.

The question is was she reminded of her options?  If she was a patient in my practice, she would have benefited from a team effort that constantly worked to keep her healthy.  At every office visit, whether with a primary care doctor or a specialist, every patient at every check-in received a personalized checklist that is age appropriate.  Ms. Edwards would have seen on her checklist that she was overdue for her mammogram.

To make it incredibly easy to get it done, all of the medical offices that her doctors work at have a radiology department with mammogram machines.  To make it even easier, patients can walk-in to have them done.  No appointments needed.   No paper work required.  She simply would have finished up with her doctor, checked in with radiology, and had her mammogram.

If by chance she was busy and otherwise healthy and hadn't seen a doctor face to face, but was overdue then she would have been notified by mail at least three times to remind her of that fact.  A team of healthcare providers use the electronic medical record to find which women are overdue, contact them, and then check again to see if the mammogram was done.  If after a few attempts if there still was no response, her primary care doctor would get a message to call her, just to make sure she fully understood the choice she was making.  If she still declined, while that would not be the medically advisable, her decision would be respected.  After all, she is an adult and would have been fully informed about the pros and cons of her decisions.

It's likely, however, that instead of a four year absence, she would have opted for a mammogram.   It would have shown an abnormality months before she actually felt a lump.  Chance of recurrence is much less when breast cancer is caught at a non-palpable stage.

Despite all of the advances in oncology and chemotherapy treatments, the biggest decline in breast cancer deaths over the past 25 years was due to mammogram screening.  Though the new healthcare reform bill which make preventative services like screening for cancer free, that isn't enough.  If people are too busy to remember, much like doing the right thing for retirement planning, they won't do what is in their best interest, even if it is what they would have done if they only had time.

In other words, it isn't about the individual as much as enabling the individual to do the best for herself by designing the system to get the best outcome.  It is true in retirement planning and automotive and road design as it is in healthcare.

I don't believe that if she had such a healthcare system in place to help her stay healthy and well that her life would have ended this way.  While the system I describe exists today in California, where I work, and our breast cancer screening rates are far far better than the study quoted at the San Antonio Breast Symposium, any death that was too soon and preventable in my mind is a failure.  A failure not of the individual patient, but of the healthcare system.

Perhaps that is why she was a health care activist.

Although I've never met her, I am certain that given a choice had she had the healthcare system around her which optimized her chances for the right decision, she would have never wanted to leave her children at such a young age.  The absence of such a system is the true tragedy.

My thoughts are with her family, friends, and most especially her children, Cate, Emma Claire, and Jack.

Why Doctors Need To Be Less Like Chuck Yeager and More Like Captain Sullenberger

A recent medical error of a wrong site surgery that occurred in one of the country's best hospitals, Massachusetts General, reminded me why doctors need to be less like Chuck Yeager and more like Captain Sullenberger.  Growing up I always wanted to be a fighter pilot, years before the movie Top Gun became a part of the American lexicon.  My hero was World War II pilot Chuck Yeager, who later became one of the country's premier test pilots flying experimental jet and rocket propelled planes in a time when they were dangerous, unpredictable, and unreliable.  Much like the astronauts in the movie, the Right Stuff, Yeager and his colleagues literally flew by the seat of their pants, made it up as they went along, and never really knew if their maiden flight in a new aircraft might be their last.  They were cowboys in the sky wrangling and taming the heavens.

Fast forward to January 2009, when shortly after takeoff a one in a million chance, a double bird strike completely disabled a US Airways jetliner.  Captain Chesley Sullenberger with the help of his co-pilot Jeff Skiles ditch the aircraft in the Hudson River in under four minutes even as the nation surely expected a tragedy.  But not on that day.  Not with that pilot.  Though Sullenberger, an already accomplished pilot from being the top cadet at the US Air Force Academy, an aviation safety expert with his experience as a crash site investigator for both the military and civilian sector as well as an instructor for US Airways pilots, he credited much of the success to his training and his experience.  Sullenberger had studied why pilots and crews often failed in critical emergency situations.  He also mastered and understood the physics and performance aspects of the aircraft he flies (his wife calls him a pilot's pilot).  He also believes strongly and instinctively the need to follow checklists and protocols to ensure the right thing is done every time.  This was drilled in him in the military where the difference between life and death in a fighter plane could be simply a matter of feet and seconds.

Though the media dubbed the landing as the "Miracle of the Hudson" and named him America's hero, Sullenberger modestly noted he was simply doing his job, which only endeared him even more to a country looking for positive stories in a time of a new president, an unprecedented financial crisis, two wars, and an uncertain future.  Ask Captain Sullenberger, review the cockpit recordings, and you'll discover that he wasn't really flying by the seat of his pants but was very methodical, rational, and logical as he quickly evaluated his three options: return the plane back to LaGuardia, go to Teterboro, New Jersey, or ditch in the Hudson River.  While planning for a landing after the unthinkable, his co-pilot automatically did his job attempting an engine restart by cycling through the checklist seven times.  They landed the plane successfully with a little luck, a lot of skill, and a full understanding of how humans make mistakes in particularly stressful times and what mechanisms when put into place, checklists, protocols, and training, can decrease these to a minimum.  Frankly, no one else could have landed that plane except Sullenberger.

Which brings me back to the medical error noted in the New England Journal of Medicine.  Dr. David Ring, after a day of many carpal tunnel surgery releases erroneously performed the surgery on a woman who was supposed to get a trigger finger release.  Though he has been praised by many to be courageous to publicly acknowledge the error, what was quite disturbing was his one comment:

"I no longer see these protocols as a burden. That is the lesson."

His insightful comment should not be seen as an anomaly.  Dr. Ring should also not be ostracized.  He speaks the truth.  Doctors today still see themselves as cowboys, the heroic individual who despite whatever obstacle or hardship can just get the job done.  Somehow, we are too smart to rely on surgical timeouts, checklists and protocols.  Instead, we refer to the entire process "cookbook" medicine and go through the motions just to appease regulators and administrators.

It is this arrogance and hubris that pervades our profession that is quite disturbing and equally disappointing.  A March 2010 report found that medical schools are not doing enough to prepare future doctors on how to develop the mindset for patient safety.  Yet for much of medicine, we understand the precisely the science of how to do things better.  No central line infections occur when all doctors abide by a simple 5 point checklist developed by John Hopkins intensivist Peter Pronovost.  Merely having every surgical team member introduce himself before surgery as noted by New Yorker writer and general surgeon Atul Gawande improves communications so that the team is more likely to function better in times of crisis.  Even a singular phone call by Dr. Gawande to the blood bank to hold blood on standby for a "routine" surgical procedure, which he had done many times before and never needed the blood, ended up being critically important.  On that day with that routine surgery, his patient had a tear which required 30 units of blood.  If Dr. Gawande hasn't called for blood on standby before the operation started, his patient would have died.

We know much more about medicine since the development of antibiotics, antiseptics, and best practices, yet we act no differently than 150 years ago.

"In 1852, the Massachusetts General Hospital was featured in a New York Times article detailing a series of events that led to the death of a young patient. Under the care of the surgeon, Dr. John Collins Warren, the patient had received chloroform instead of the usual chloric ether anesthesia. The event that we describe here, more than 150 years later, is a sad reminder that despite expert and well-intentioned providers, our patients continue to face risks caused by human fallibility and systems that do not fully support our efforts to provide safe care."

It's time doctors stopped acting like the cowboy test pilots of Chuck Yeager's era and adopted the mindset of Captain Chesley Sullenberger and doctors Pronovost and Gawande.  Protocols and checklist exist for the safety of our patients and to ensure highly reliable outcomes everytime.  Until doctors all adopt this mindset, medical errors will continue to happen despite policies and regulations because somehow our profession still believes we are infallable.

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.

The Best Health Insurance - Can Save Your Life

The Sacramento Bee recently ran the following opinion piece below.  A couple of additional comments not published follow.  Enjoy. 

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It’s that time of year when most of us pick a health insurance plan based simply on cost. It’s a belief that is often perpetuated by friends, family, and advice dispensed by many articles in magazines and newspapers. As a practicing primary care doctor, I can tell you that the advice is frankly wrong.

Health insurance isn’t a commodity like auto insurance. It’s not just about the price. They aren’t all equally good at keeping you healthy and well. The recent annual report by the National Committee of Quality Assurance, which has been evaluating health plans for twenty years, continues to report tangible differences among health insurance plans across the country as well as in California.

In a ranking of 227 HMO plans nationwide in important areas like immunization rates for children, appropriate use of antibiotics, blood pressure and cholesterol control, cancer screening in adults for breast cancer, cervical cancer, and colon cancer, only two of nine California HMO health insurance plans ranked in the top 15 percent. The remaining seven were in the bottom half. If all health plans across the country performed at the level of the top 10 percent, 186,000 Americans would be alive today. They would have consistently and routinely received the preventive care and medical interventions that have proven to save lives.

Naturally, it is hard to believe that your choice of a health insurance plan might actually save your life. You often pick your insurance based not only on price, but also if your doctor is in the plan. As a patient, high quality care means your doctor sees you quickly when you are ill, he is always willing to listen and explain, and the fact that he actually knows you as an individual. As a result, he should know what to do to keep you healthy, even as research points to the contrary.

A recent study by the Journal of General Internal Medicine found that only 20 percent of doctors correctly screened patients for colon cancer, the second leading cause of cancer deaths. The doctors likely to do the right thing were younger, board-certified, and used electronic medical records. Those most likely to incorrectly screen or not screen at all were older, much like the fictional television doctor, Marcus Welby. He’s a doctor we would all feel comfortable with and we would trust to keep us well.

Who did better, a health plan or a doctor? The HMO health insurance plans in the top 10 percent of performance screened 72 percent of their enrollees appropriately for colon cancer, three and half times more than the doctors. The bottom 10 percent screened 47 percent of patients. The news for enrollees in the more popular PPO plans is more worrisome. Screening rates of these plans were only 54 and 39 percent respectively for the top and bottom 10 percent of plans.

It’s not obvious the reasons for this difference in performance among health plans or the difference between doctors and health plans. Do better health plans have systematic ways of keeping patients healthy or reminding doctors at the point of care? Is it that doctors who are better naturally gravitate to health plans that are focused on prevention? After all, the work of screening and providing the preventive interventions are done by doctors not by insurance companies.

As a practicing primary care doctor, I constantly balance the art of medicine, the bedside manner, and the science, the evidence based research. Before I joined with a high quality health insurance plan, I thought I was pretty good. The initial data showed otherwise. Over the past few years, I’m far better at keeping my patients healthy. With this insight I now know that given a choice, I would always start with health insurance quality first and then the doctors selection second. It doesn’t sound right. It doesn’t feel right. The science part of my medical degree says it is right.

The striking difference between health plan performance means that a choice most of us view as a simple formality or even an annoyance, picking a health insurance plan, is really a choice between getting the best care or not. A true choice between life and death. Intellectually this doesn’t make sense. Doctors take care of us. They are accountable to keeping us well, yet the data and research seems pretty compelling.

This year 186,000 Americans won’t have the opportunity to make the right choice because the health plan they had wasn’t high quality.

Will you make the same mistake this year?

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The two California HMO plans that were in the top 15 percent in the nation were Kaiser Permanente Northern California and Kaiser Permanente Southern California.  Each takes care of more patients than the entire top 10 HMOs combined.

Abraham Verghese - The Top Gun of American Medicine

The first year medical students I precept were too young to see Tom Cruise's alter ego Lieutenant Pete "Maverick" Mitchell grace the big screen in the 1986 blockbuster film Top Gun.  Yet, the story has a relevant analogy to medicine. 

According to the film, during the Vietnam war American pilots were relying too much on technology to bring enemy fighters down.  They weren't as skilled in taking out the opposition.  They fired their technologically advanced missiles to try and get the job done.  They didn't think.  It didn't work.  They forgot the art of dogfighting.

The military discovered that technology alone wasn't going to get the job done. The best fighter pilots needed the skills, insight, and wisdom on when to use technology and when not to. As a result, the Navy Fighter Weapons School, known simply as Top Gun, was created to retrain the military pilots on this vital lost skill. 

The goal of the program was specifically to make the best of the best even better.

Like the military, the country is discovering that the healthcare system enabled with dazzling technology isn't getting the job done either.  One study suggests that Americans don't live as long as citizens from other industrialized countries not due to our obesity or smoking habits but because of the failings of the healthcare system even though we pay more per capita on healthcare.  Since the recent and current generation of doctors, residents, and medical students are trained to rely heavily on technology, the situation is only going to get worse.  These doctors do not know how to do a thoughtful history or thorough physical examination.  Individual patients as well as the nation will pay a price for more unnecessary testing as well as wasted time and money which could have been avoided if doctors focused on the art of medicine. 

To slow healthcare costs, the next generation of doctors will need the skills, insight, and wisdom on how to take an accurate history, perform a thoughtful clinical examination, and use technology judiciously.  They must be experts in the art of medicine.  Like the art of dogfighting, the art of medicine was a skill that should have been embraced as technology proliferated instead of being marginalized in training.


So who are medicine's Top Guns?  Who are the best of the best?  Where is medicine's Navy Fighter Weapons School?

If medical students want to be the best of the best, then they should look no further than Dr. Abraham Verghese of Stanford Medical School.  Dr. Verghese, already an accomplished author who is also board certified in internal medicine and infectious disease, engages them with the virtuoso performances on the fine art of medicine.  For doctors to become expert diagnosticians, he and his colleagues outlined 25 skills doctors should know simply as a beginning to more learning.

If students want to be in the specialty where the best and brightest work, then they should look no further than primary care, family medicine or internal medicine.  Besides dermatology, primary care is a specialty where doctors often start evaluating patients by talking, observing and examining.  Primary care doctors often see patients for the first time without any test results as these visits are usually the first time someone has sought medical care.  As a result, they need to skills to figure out which patient needs more extensive work-up and which one can safely care for the problem at home.  Though primary care isn't as attractive to medical students and proposals are underway to make the field more appealing, there is no question that it is the most cognitive specialty - a doctor's doctor specialty.

If the US healthcare system is to provide Americans better care it will need a generation of Top Guns in primary care to lead the change.  What Dr. Verghese offers his medical students and residents in his training is what all of us want in our doctor - someone who listens, observes, and examines thoughtfully to get the right diagnosis.

In other words, a doctor who is the best of the best.  As a practicing doctor, I would jump at the opportunity to learn from him.