No effective screening test for ovarian cancer, yet

A recent study found that annual transvaginal ultrasounds with annual blood tests for a tumor maker CA125 did not pick up ovarian cancer at an earlier stage. A retrospective study, it looked at 341 women with a family history of ovarian cancer. Of the four that had ovarian cancer, only one was detected at surgery and the other three developed ovarian cancer between the screening tests.

The authors concluded that for women who are at average risk for ovarian cancer (i.e. no family history), that "ovarian cancer screening should not be offered unless it is within a clinical trial aimed at developing new methods for ovarian screening."

It is frustrating for both doctors and patients that there is no current effective screening test for this deadly disease. This is probably why in June 2007, the American Cancer Society as well as the Gynecologic Cancer Foundation, and the Society of Gynecologic Oncologists issued a press release about symptoms women should watch out for that could be early signs of ovarian cancer.

Specifically:

• bloating
• pelvic or abdominal pain
• trouble eating or feeling full quickly
• urinary symptoms, such as urgent or frequent feelings of needing to go

Although the above conditions are more likely to be due to other less serious conditions, patients are encouraged to see their doctors, preferably gynecologists, if the symptoms are present daily and last more than a few weeks. The fact that this is the best these expert groups can recommend means that there is still a lot more research that needs to be done.

NY Times mention of my book!

I'm absolutely thrilled that Jane E. Brody, writer of the personal health section of the New York Times, briefly mentioned my book Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System in her weekly column which appeared in the Christmas Day edition. Titled "On the Same Wavelength With the Doctor", it provides tips on how to get the most out of increasingly shorter office visits.

I'm hopeful that she and others will find value in my book. What she discusses is just a very small section in the book, which is loaded with critical information everyone needs to stay healthy and well while spending wisely.

Medical Myths - Revealed!

A recent article in the British Medical Journal reveals commonly that the repeated medical myths that may individuals and doctors repeat as true have little to no scientific basis. Sometimes an opinion becomes a fact if repeated often enough. Some of the medical myths include:

• People should drink at least eight glasses of water a day
• We use only 10% of our brains
• Hair and fingernails continue to grow after death
• Shaving hair causes it to grow back faster, darker, or coarser
• Reading in dim light ruins your eyesight
• Eating turkey makes people especially drowsy
• Mobile phones create considerable electromagnetic interference in hospitals

A Simple Checklist - Can It Save Lives?

Atul Gawande, a surgeon at Harvard as well as staff writer for the New Yorker, has penned a couple of excellent books, Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. His most recent piece, The Checklist, is no exception. Improving the delivery of care isn't so much about overhauling it with radical changes, but simply looking at how to little steps enhance the process of delivering that care.

Excepts from his most recent article:

• A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient.
• Here, then, is the puzzle of I.C.U. care: you have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” So how do you actually manage all this complexity? The solution that the medical profession has favored is specialization.
• Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.
• In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years.
• Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
• The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary...The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
• Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

Don't Tell

Doctors are human after all, so perhaps the findings from the Annals of Internal Medicine titled, "Professionalism in Medicine: Results of a National Survey of Physicians" isn't that surprising. A summary from Reuters illustrated the following:

• 46 percent of physicians surveyed admitted they knew of a serious medical error that had been made but did not tell authorities about it.
• 96 percent of those surveyed said they should report all instances of significant incompetence or medical errors to the hospital clinic or to authorities.
• 85 percent of most doctors said they should tell patients or relatives about significant errors.

the reality was far different.

• Forty percent of the doctors said they knew of a serious medical error in their hospital group or practice but 31 percent admitted they had done nothing about it at least once.

The article also found that nearly a quarter of the 1600 doctors surveyed didn't feel that periodic certification was desirable.

Conclusion? Doctors are human as well and naturally do things in their best interest. Is the lack of reporting due to a medical culture where error and omissions aren't openly talked about? Why would a good number of doctors oppose periodic re-certification? Medicine changes constantly and what was good a few years ago is no longer the standard of care. Concerning but perhaps not surprising. This behavior needs to change for significant improvement to occur in patient safety.

Antibiotics Aren't Necessary

Not a surprising report, except perhaps to many patients, that antibiotics aren't generally needed for sinus infections. Earlier this year the professional society of otolaryngologists, that's ear, nose, and throat doctors, had a similar statement. Sinus infections generally are caused by viruses. Those infections that need antibiotics are often those where a head cold was improving and then suddenly got worse.

Don't be shocked if your doctor doesn't prescribe antibiotics before for something which was done in the past. With more resistant bacteria, like MRSA, it is important that we save antibiotics only for conditions that require it. If you do get antibiotics, finish it completely even if you are feeling better. Not completing a full course of treatment is another cause of increasing bacterial resistance.

With all of this knowledge, don't you feel better already?

Adults Often Skip Doctor's Treatment

In a Harris Interactive / Wall Street Journal survey titled Many U.S. Adults Disregard Doctors' Course of Treatment a surprising number of individuals (44 percent) reported not following a doctor's recommendations because they felt the treatment was unnecessary or overly aggressive. One in five sought a second opinion because the recommended treatment was perceived as too aggressive.

Over half believed the reason for this over treatment was due to doctors protecting themselves from potential lawsuits. Over 40 percent felt it was because doctors were catering to patient demands or for doctors to make more money. One out of four felt the unnecessary added care was due to faulty medical diagnosis or fast and easy decisions.

Are the results surprising? It sounds like plenty of miscommunication between patients and doctors. With face to face time with doctors getting shorter, it is even more important that you say the right things and that you are heard otherwise you may get more than you ask for.

High Cost of Health Care

A New York Times editorial titled the High Cost of Health Care succinctly and correctly identifies the factors resulting in current predicament of the American healthcare system. We pay more for our doctors and our hospitals. We use more specialists who utilize more expensive tests and procedures. The issue is at the current rate of spending, the federal program Medicare, will bankrupt the budget, much the same way healthcare costs has done with employers, who now are reducing benefits or dropping health insurance offerings completely.

The solutions are mainly to do what is known to work.

• Practice effective evidence based medicine consistently and regularly throughout the country. This is only being done about half the time. There is no difference in medical outcomes and it is done at less cost.
  
• Improve how primary care doctors are compensated. Industrialized countries that have lower healthcare costs have a robust system of these preventive medicine specialists.
• Implement information technology widely so that the healthcare system benefits from the same efficiencies that other industries have uncovered.

A single payer system isn't the perfect solution. The "Medicare for all" as some have portrayed the single payer system to cover the 47 million uninsured isn't as simple as it sounds. Medicare and social security are the largest federal entitlement programs and without major reform, both will bankrupt the federal budget. The editorial correctly identified the potential pitfall of relying completely on consumer driven healthcare. Do consumers really know what they are getting when it comes to their health?

Solving the healthcare crisis in America requires a uniquely American solution. To understand what needs to be done you must understand the fundamentals about our healthcare system. The NY Times editorial objectively describes the issues and potential solutions and is an important read for all.

Second Opinions - Online - Worthwhile?

What would you say are the pros and cons of getting a second opinion online through institutions like The Cleveland Clinic and Partners Healthcare (through Harvard)?
Second opinions online or consultations without seeing or examining a patient are probably helpful if someone wants to have the blessing of a major medical institution like Cleveland Clinic. The other advantage is to get advice without traveling to these medical centers. While these second opinions have access to doctors’ notes, lab results, and imaging studies, these institutions don’t usually have their doctors examine the patients. This is the biggest potential problem of these programs.

Let’s for example say you wanted to buy a car. If you wanted to buy a car online, could you make an informed decision whether to purchase it based on its description (doctors’ notes) and pictures (imaging studies)? Would you be able to tell if the engine ran smoothly, the seats were comfortable, or the handling was just right based on the information you received online? For most people, doing the research and having bits of information isn’t a substitute for a test drive.

This is no different than having an online consultation. As doctors, one of the first things we learn is to treat the patient and not test results. People are more complex than simply blood tests, MRIs, and CT scans. Often pathology and radiology reports are qualified with the phrase “clinical correlation recommended”. This is the pathologists’ and radiologists’ way of telling the doctor who ordered the test to realize that the information they provided is only helpful in the context of the patient. Pathologists and radiologists know their limitations. Their expertise provides only a glimpse of the person and his medical condition. This is the main reason that medical students today still spend much of their time learning how to interview and examine a patient before they learn what tests to order.

If the online opinion was used to reaffirm another second opinion, where a patient was examined by a doctor, then this would be reasonable. It would be very concerning if this second opinion overturned or refuted a previous opinion particularly since the patient wasn’t examined. Doctor notes, test results, imaging reports provide only a partial picture of a patient or his condition.

Second Opinions - Blinded and Two Different Options

What is a "blind second opinion"? What are the advantages and disadvantages?
A “blind second opinion” is seeing another doctor, but not providing him any of the other doctor’s notes, lab results, x-ray results, or biopsy results. Advocates feel that by not giving the second opinion doctor any information that it makes him more objective and less likely to be biased by the first doctor’s work-up and assessment. The problem is that since the second doctor is essentially starting from scratch, the patient may need to undergo repeat testing which may be costly. Also, if the second opinion differs from the first, it won’t be clear to the patient why the doctors disagreed with each other since neither one has access to the other’s information.

For a second opinion to be worthwhile, patients should provide the doctor all of the previous doctor notes and results so that he understands what has already been done. What makes it a great second opinion is having the doctor now step back, ask and examine the patient as if it was the first time seeing him, ignore the medical record, reach his own conclusion and then see how his opinion either supports or refutes the diagnosis and plans of the first doctor. If you see a doctor who keeps pushing you to talk about your symptoms and treatments and not what other doctors have said or what the tests showed then you’ve found yourself with a doctor who will give a great second opinion.

If a patient gets two opinions on a condition and they vary greatly, how does one make a decision?
If there is this situation then it means that for that particular condition there is not a general consensus or agreement on what the best treatment is. In this case, there are a few of options. One is to get a third opinion and see if it provides a middle ground between the first two cases. The other option is to get a third opinion, but have it with a guru or nationally renowned expert on the condition. It is possible that with these options that there might be three very different opinions. In this case, the best decision is to find the doctor who suggested a treatment plan the person was most comfortable with. With three opinions for the same condition, it is even more clear that there is no agreement and therefore a person can’t be truly faulted for making a less than ideal choice as three doctors couldn’t agree. What is most important at that point is that the patient makes a choice he is comfortable with.

Second Opinions - How

What is the best way for a patient to approach her doctor about getting a second opinion?
The best way is to tell the doctor that you appreciate their care.  For you to proceed further it would help you to get a second opinion.  You want to know if there are other alternatives or ideas. If you aren’t the one wanting the second opinion, then I would suggest that you tell your doctor that it is your loved one or family member that is requesting it. Reassure the doctor that you wish to continue care with them, but wanted to explore the possibility of other options.

Good doctors shouldn’t be offended. If they are comfortable with their diagnosis and treatment plan, they know that you aren’t likely to find alternative therapies. Good doctors also know that they don’t know it all and they welcome the opportunity to learn something new from a second opinion. Finally doctors are notorious for asking for second opinions when they are patients, as they all understand some of the uncertainly of practicing medicine, and aren’t shy about asking for one. It is your health. Having regret of not asking for a second opinion is worse than having to perhaps bruise an ego. Again, good doctors aren’t offended, often expect to be asked for second opinions, and will suggest a patient get a second opinion in a particularly serious medical condition.


What should patient and doctor discuss under these circumstances?
Say that you very much appreciate their care and value their advice. You wondered if there were alternative treatment options or therapies that other doctors might be familiar with that he would recommend for a second opinion. Reassure the doctor that you will be coming back to his practice and this request is simply more for your piece of mind, or that of your loved one. Explain that you are very satisfied with his care.

Don’t demand a second opinion. If your doctor won’t help you, you can still get a second opinion. You might also want to consider switching doctors as a doctor who won’t help you get a second opinion, particularly for a potentially serious medical problem, may be more worried about his ego rather than putting you first as a patient.

How can a patient best get his primary care doctor on board if the patient decides to go a route not recommended by his doctor?
Patients need to realize that much the same way doctors can’t force patients to do certain things, like exercise more, lose weight, quit smoking, and take prescription medications, that they also can’t force their primary care doctor, whether an internist or family physician, to get on board to an alternative treatment plan. If their doctor wishes to work with them and both parties can compromise, that would be great. If not, it is best that the patient find another doctor they can work with.

Doctors are available to provide patients their medical expertise. Depending on the doctor, his experience can vary widely. Rather than trying to force a primary care doctor to get on board to a plan he doesn’t agree with, it would be better to find another doctor with the expertise you need.

Second Opinions - Where to Get One

How do patients find doctors to do a second opinion?
Patients should ask their primary care doctor, either an internist or family physician, who to see for a second opinion. Often their doctor refers patients to specialists and will be familiar with different doctor groups in the community.

Another option to find a doctor is by using the physician directory of a professional medical society. For example to find an orthopaedic surgeon, going to the American Academy of Orthopaedic Surgeons website, one can find doctors by zip code, city, or state.

The third option is to find the nearest medical school or university hospital and ask to see a doctor who is staffed there. Through these medical centers' websites you often can get a name and an idea of the individual doctor's background and experience. Because are often teaching hospitals, be sure to clarify if you only want to see that doctor or if it would be ok to be seen by one of the doctors in training. The doctors in training, interns, residents, fellows, are supervised by the doctor.


Is there an advantage of seeking a second opinion at a research and teaching hospital?
Doctors at research and teaching hospitals typically have the latest treatments and technologies available to them. They also have valuable expertise in treating rare medical problems. Patients with especially difficult diseases which has failed conventional therapies or patients with rare illnesses will often seek out these large research and teaching hospitals. Because these doctors see a large number of these uniquely challenging medical cases, their experience is far better than a doctor in the community who may only see one case in an entire career.

Patients who would get the most benefit from a research and teaching hospital are those with medical problems that are rare or that have failed traditional treatments.

Second Opinions - When and Why

When is it a good idea to get a second opinion?

Second opinions should strongly be considered when there is a potentially life threatening medical condition, like cancer, when the proposed treatment options are intensive or demanding, like chemotherapy or major surgery, or when there is a chance for a very bad outcome or complication, i.e. brain surgery. By having a second opinion, particularly in these high stakes situations, patients and their families will have the opportunity to have a second set of eyes double check to see if the original diagnosis and treatment plan are reasonable as well as a chance to hear someone else explain the problem which may be more understandable and enlightening.

With any other big decision — purchasing a new car or deciding to get married, for example — people instinctively seek out multiple opinions. Others voice their unsolicited opinion. When making a decision which could mean the difference between life or death, patients should not be shy about getting a second opinion. Patients should also ask their primary care doctor about their thoughts and understanding of the treatment plan of the first doctor and the need for a second opinion.

Why are patients reluctant to get second opinions?
Patients may be afraid that their doctor won’t take care of them in the future because they are asking for a second opinion. They may not feel the need to get a second opinion since they are comfortable with their doctor. They may not be aware that getting a second opinion is a good idea. They don’t know how to ask for a second opinion.

Do philosophies and treatment options vary among hospitals and medical practices?
Philosophies about treatment options can vary greatly depending on where and who the physician trained with, the physician’s field of practice, when the physician did their training, and the physician’s personal belief. Often for the same medical problem, different doctors, even within the same specialty, will have different recommendations and treatments. This is often a result of who they trained with and their clinical experience. Practice styles and philosophies also differ from the East Coast and West Coast.

For the example of leg pain due to a pinched nerve, some back surgeons will recommend early surgical intervention, while others suggest non-operative conservative therapy. If a doctor trained at a program that advocated watchful waiting, then it is more likely his philosophy is to be conservative. If his mentor, however, always recommended surgery quickly, then it is likely his own belief is that operating is more beneficial. After one year, research has shown that patients do equally well with either option.

For patients to see what the varying philosophies are, they will need to seek out different hospitals and practices. Even within a group practice, the doctors may have different approaches for the same problem.

Diabetes - What You Need to Do to Stay Well

This past year the New York Times printed a series about the six killers in America which included cancer, diabetes, heart disease, emphysema, stroke, and Alzheimer's. The article on diabetes shows how much more our healthcare system needs to improve to basics and fundamentals of preventive care to keep people healthy and productive. Highlights from the article include:

• Most [diabetic] patients are not doing even close to what they should to protect themselves. In fact, according to the federal Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.
• The fault for the missed opportunities to prevent complications and deaths lies with the medical system.
• A recent survey by the American Diabetes Association conducted by RoperASW found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.
• Yet, said Dr. David Nathan, director of the Diabetes Center at Massachusetts General Hospital, “when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.”"
• “Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.”
• “We already have the miracle pills” — statins and blood pressure medications, he said. And they are available for pennies a day, as generics.
• “We need patient education and physician training that this stuff is out there and this is what we should be focusing on to make a difference in lives.”

Without a doubt, the United States does deliver the most sophisticated and technologically advanced medical care in the world. This is why patients come here to get care that they can't get anywhere else.

That doesn't mean that we do a great job with simple things like vaccination rates, cancer screening, and control of high blood pressure, cholesterol, and diabetes, to levels recommended by expert committees. Although the level of care has improved over the past decade as evidenced by reports from the National Committee for Quality Assurance, there is more we need to do.

Vaccine against "infant killer"

Doctors in Macau, which is near Hong Kong, want the government to pay for the pneumococcal vaccine to protect against Streptococcus pneumoniae. The bacterium dubbed "infant killer" claims nearly 50 children per hour in Asia. The bacterium is already resistant to many antibiotics. Unfortunately the cost of the vaccine is out of reach for many in Asia.

Lui Kin Man, president of the Macau Paediatric Society, said childhood vaccination against the bacteria was important in southern China because treatment was especially difficult.

"In our region, like Hong Kong, Macau and Taiwan, bacterial drug resistance is very high, and pneumococcal (bacteria) is resistant to drugs like penicillin and erythromycin," Lui said in a telephone interview.

"Mortalities (caused by the pneumococcal bacteria) are higher in developing countries and mostly from pneumonia. Of all pneumonia deaths, 40 percent of them are caused by this bacteria," Lui said.

In the United States, prior to the development of a vaccine that protected against Streptococcus pneumoniae, the bacteria annually caused over 700 cases of meningitis, 13,000 cases of blood infections, over 5,000,000 ear infections, and 200 deaths in children under five from invasive disease.

In America, children are routinely offered this vaccine. Recommendations by the Centers for Disease Control suggest that for children, the vaccine is a series of shots given between the age of two to twenty-three months and is known as the pneumococcal conjugate vaccine (PCV). Other children may also get this vaccine at a later age if they have certain medical conditions. The pneumococcal polysaccharide vaccine (PPV) is recommended for adults sixty-five and older or who have other medical conditions. PPV is also given to children over the age of two with chronic illnesses.

With immunization, parents don't need to worry that there children will contract the illness or a bacterium that is resistant to many antibiotics. Yet, in this country many parents question the importance of vaccinations as doctors and parents a world away wish they had the opportunity to immunize.

War on Obesity - at the Workplace and School

A report in the journal Circulation found that around the world, except for East Asia, the majority of individuals are overweight or obese. The study looked at nearly 170,000 patients across 63 countries, but excluding the United States, to see if their body mass index was in the overweight or obesity range. The report was somewhat skewed as the researchers look that those individuals who were seeing their primary care doctor.

Researchers found that of men 24 percent of men were obese and 30 percent were overweight. For women the numbers were higher at 27 percent of women were obese and another 40 percent were overweight.

These results are not surprising as many countries are opting the Western lifestyle of fast food and inactivity. It is unfortunate that one of our country's major export is to make people fatter.

Perhaps stemming the tide of this international epidemic of obesity will rely on innovative programs that are occurring in the workplace and at schools in the United States. Increasingly employers are trying to slow their health care costs by encouraging employees to quit smoking or lose weight. A few have actually terminated individuals who were found smoking. More Americans feel that those who adopt unhealthy habits should pay more for health insurance than those who are healthy.

The other area of opportunity is changes in food options available to school children. A CDC report found that the number of schools that offered french fries as their only vegetable fell by half from 40% in 2001 to under 20% in 2006. Schools are removing sodas and other junk food from their vending machines and cafeterias. Physical education programs, once cut because of inadequate funding or time due to additional academic requirements, are being re-introduced to get students more active.

Providing environments that are supportive of healthy choices and lifestyles may help current and future generations avoid the overweight and obesity problems currently plaguing too many individuals.

America's Lagging Health Care System

An editorial from the New York Times reiterates what has been known for quite sometime which is that the American health care system trails that of other industrialized countries. More individuals are becoming dissatisfied with a system that does not support quality, leaves too many without insurance, and continues to increase costs.

The editorial correctly points out that for the system to improve it will require that patients have easy access to primary care doctors. It is the robust primary care doctor network that other countries have that help improve the health of their citizens while keeping costs manageable.

Healthcare Failings Due to Not Doing the Basics

For anyone interested in understanding what drives a lot of the costs in the healthcare system, the New York Times health series about the six killers in America, heart disease, cancer, stroke, chronic obstructive pulmonary disease (emphysema), diabetes, and Alzheimer's is an excellent place to start.

Some themes begin to emerge. For heart disease, the way to prevent future heart attacks is to ensure that patients understand how to take their medications and that it is often for life. For successful cancer treatment, the goal is early detection and undergoing the simple, but for some, unpleasant tests to screen for breast, colon, and prostate cancer. For stroke, it is to ensure that missed opportunities aren't missed.

Ulimately, much of the differences between a fair outcome and great outcome is focusing on the little things - taking medications regularly and as directed, getting the preventive screening tests done, and making sure that the little things are always taken care of.

Much like any coach knows before a team can be successful, each of the players must know the fundamentals. In hockey that would be skating, stickhandling, passing, and checking. It doesn't matter how expensive your skates are or what high tech materials your stick is made out of. Unless you and your team know the basics, you will fail. Unfortuantely, the healthcare system as a whole hasn't yet mastered the fundamentals.

Lessons of Heart Disease, Learned and Ignored

A fascinating piece about heart disease not because the information is cutting edge, but rather because the failures in preventing future heart attacks are due to the inability for doctors to communicate to their patients about continuing their treatments consistently, regularly, and in most cases indefinitely. The article Lessons of Heart Disease, Learned and Ignored looks at an individual who proudly stopped taking his prescription medications after losing weight and exercising. He had his first heart attack nine years earlier and reasoned, incorrectly, that by changing his lifestyle that he could avoid taking medications altogether. Had he consulted his doctor before stopping his medications, he most likely would have avoided his second heart attack.

This is a common occurance in my experience as well. Many patients don't want to take medications that are potentially life saving because they aren't natural, yet when challenged to make significant lifestyle changes to lose unnaturally heavy weight and unhealthy habits they don't want to. Any patient should always consult with his doctor before stopping any prescription medications. If you are concerned that your doctor is simply writing medications and not working with you to keep you healthy, consider switching doctors. Realize, however, that there are situations that medications must be taken to keep you well. That perhaps is the most difficult idea for many patients to swallow.

Healthcare Reform - Dutch or Swiss?

The New York Times reported that Health and Human Services Secretary Leavitt was going to Switzerland and the Netherlands to see how these countries provide healthcare. In those countries there is an individual mandate, i.e. everyone has to buy health insurnace. Employers are not required to provide health insurance.

Unlike Canada and Great Britian, it appears these countries don't use the government set up the system. Will elements of the Swiss and Dutch healthcare systems work here? It probably will depend on who sits in the White House and who controls Congress.

Adult Vaccination Update

As it does regularly, the CDC revised its recommendations for adult vaccinations. Now adults who are worried about shingles or zoster, which is a very painful skin eruption that typically occurs in older adults, can get vaccinated at 60 years of age. Also new is the recommendation that all adults without proof of immunity to the chicken pox (varicella) virus should get vaccinated.

Not sure what immunizations you need? Print out the adult vaccination schedule and have your doctor explain. It's the easiest way to make sense of the alphabet soup of immunizations. In the 21st century as an increasingly number of bacteria are more resistant to antibiotics and viruses exist that can cause debilitating illnesses, vaccinations continue to have a role in keeping people healthy. Most of us immunize our children. Adults deserve the same level of care. Talk with your doctor the next time you see her.

Too Many Drugs?

The New York Times article titled "The Poisonous Cocktail of Multiple Drugs" illustrates a fairly common occurance for many patients, taking multiple prescription medications. Known as polypharmacy, patients have many different medications prescribed by multiple doctors who don't know what the other one wrote. As a result, these patients, unfortunately, are at higher risk for having medication side effects or interactions.

As people live longer with more chronic illnesses, their care becomes more complex. This is why patients may find it valuable to have one primary care doctor coordinate care and ensure that the treatments rendered by various specialists are compatible with each other. The other is having technology like the free web-based eRx Now system to help busy doctors check different medications for drug interactions and track a person's treatment.

Without either of these interventions, the case of the 78 year old lady who passed out from a stomach ulcer due to the combination of aspirin, ibuprofen, and Celebrex, will undoubtedly continue.

Finding the Right Doctor

A recent article in the Atlanta Journal Constitution titled "Rx for a doctor: Here are some tips for finding the right physician" had comments from yours truly.

Overall, it provides an excellent starting point on how to find a primary care doctor.

Better Screening Test for Cervical Cancer - Are Pap Smears Obsolete?

Very exciting news about the war against cancer. A published article in the New England Journal of Medicine found that screening for the human papilloma virus (HPV) was far more accurate in detecting cervical cancer than the current PAP smear.

Highlights from the article.

The HPV test, which looks for the virus that causes cervical cancer, correctly spotted 95 percent of the cancers. The Pap test, which checks for abnormal cells under a microscope, only found 55 percent, according to researchers at McGill University in Montreal.

The Canadian study, which was government-funded, included 10,154 women ages 30 to 69 in Montreal and St. John's, Newfoundland. The women got both tests. Still to be determined is the best way to start using the HPV test by itself and what follow-up action to take after positive results, the researchers said.

Dr. Carolyn D. Runowicz, who wrote a journal editorial, noted that the two studies used a different kind of Pap test, not the liquid-based technology used in the U.S, which may be more sensitive The results of a British study that used liquid Pap are due to be presented in November.

"We're not ready for prime time. We're moving in that direction. But we're not there yet," said Runowicz, a former president of the American Cancer Society.

Troubling Trend of Avoiding Vaccinations in Children

A recent article noted how more parents, skeptical about the value of vaccinations and worried about the linkage of immunizations with other problems like autism, are using religious grounds to be exempted from mandatory childhood vaccinations.

This troubling trend is fortunately relatively small. Highlights from the article.

• The number of exemptions is extremely small in percentage terms and represents just a few thousand of the 3.7 million children entering kindergarten in 2005, the most recent figure available.
• In 1991, a religious group in Philadelphia that chose not to immunize its children touched off an outbreak of measles that claimed at least eight lives and sickened more than 700 people, mostly children.
• And in 2005, an Indiana girl who had not been immunized picked up the measles virus at an orphanage in Romania and unknowingly brought it back to a church group. Within a month, the number of people infected had grown to 31 in what health officials said was the nation's worst outbreak of the disease in a decade.

I understand the parents' concerns. I also am more concerned that people have forgotten how many of these illnesses, like polio, measles, mumps, were debilitating and devastating in the past and that generations of adults, through the use of vaccines years ago, have avoided those complications or premature and preventable deaths.

This past winter, I saw first hand how powerful and effective vaccinations are. When I examined one patient, in his late 30s who was vaccinated against influenza, he felt well in a day or two despite having the flu. This was in stark contrast to other patients in their early 20s, who weren't vaccinated, felt miserable, stayed in bed for days, and wanting to die (they didn't of course). If you've had the flu, you know what they mean, fever often up to 103 to 104 F and every muscle, joint, and bone aching relentlessly. On follow-up months later, the latter group all without hesitation planned on getting the flu shot this fall, even though they are not required to based on current vaccination guidelines.

With recent reports about the rise of bacteria that are resistant to all antibiotics resulting in 19,000 deaths and the findings that cervical cancer is caused by the human papilloma virus (HPV), individuals skipping vaccinations maybe missing opportunities to stay healthy.

Those who cannot remember the past are condemned to repeat it.
* George Santayana (1905) Life of Reason vol. I, ch. XII Charles Scribner's Sons

Insurance Type and Appendicitis

An interesting article in the New York Times titled "Likelihood of Burst Appendix Tied to Insurance".

From the report, "But the kind of insurance — or lack of it — had a significant effect. Compared with patients who had private insurance coverage, those on Medicare were 14 percent more likely to have a burst appendix, people on Medicaid were 22 percent more likely, and those with no insurance at all were 18 percent more likely to have a rupture. The differences persisted even after controlling for age, sex, socioeconomic status, type of hospital and other factors."

The authors admit that this is a retrospective study and it is unclear the reasons why the difference was seen.

Heart Disease - Thank You Framingham Heart Study

Recently saw this update about the famous Framingham Heart Study. Everything we know it medicine is a direct result of volunteers and doctors who 60 years ago embarked on understanding what the risk factors were for heart disease. Although today we take the risk factors for granted, smoking, high blood pressure, cholesterol, it wasn't entirely clear decades ago. Excerpts from the article.

"The death of President Franklin Roosevelt on April 12, 1945, was the wake-up call that eventually led to the study. On the day he died, Roosevelt's blood pressure was an unbelievable 300/190. Few doctors then even suspected there was a connection."

"The early findings were bombshells: smoking, cholesterol, high blood pressure, fat consumption and obesity. At first the nation was in denial. Who knew lifestyle and cardiovascular disease were connected? Practically everything we know now about heart health originated with the Framingham Heart Study. "

"Every advance in technology, every scientific breakthrough means that the longer the study goes on, the more valuable the data it generates - three generations of genetic gold to mine."

All of us, the public and doctors, owe a debt of gratitude to these individuals. Without their volunteerism as well as foresight, where would we be today?

Health Insurance - Odds 1 in 3 Yours Isn't Doing Everything to Keep You Well

One hundred million insured or one in three Americans have no idea if their health insurance plan is doing everything to keep them healthy. This ignorance could cost them their lives. This is the conclusion from the recently released 2007 State of Health Care Quality report by the National Committee for Quality Assurance, a non-profit organization which for over a decade has accredited health insurance plans for their performance. NCQA rates health plans on their ability to provide their enrollees with basic and proven preventive treatments, controlling high blood pressure, diabetes, cholesterol, among many others, consistently and routinely. While the industry has made significant improvements, much more needs to be done to save lives.

When NCQA started reviewing the quality of care delivered, it found that in 1996, on average only 62% of heart attack patients were getting beta blocker medications. These medications have been proven to decrease the risk of future heart attacks and prescribing them to these patients has been the standard teaching in medical schools for years. Over the past decade on average 98% of the time heart attack patients in health plans accredited by NCQA receive this treatment.

Unfortunately, health plans that didn't submit information for review did less well with 94% of patients getting the prescribed medication. Although it most situations this would be good enough, each drop in percentage translates into lives that could have been saved with a simple proven intervention.

Because this and many other effective preventive treatments weren't done to the level recommended by expert committees, 75,000 insured Americans died prematurely. Had these individuals accessed high performing health plans they would be alive today. If the entire industry performed as well as the top plans, $3.7 billion spent on hospital costs would have been avoided. Preventive care saves lives and money when done consistently and regularly. The problem is that within the healthcare system this is far from the case.

Part of the problem is that the most popular insurance plan, the PPO plan, does not have the same level of scrutiny when it comes to performance or accountability like a HMO plan. Until last year, no PPO plans provided NCQA any information on how well they did to keep you well. This year, those plans that cover one hundred million Americans still have not committed to submitting information for review. This lack of transparency has California's insurance commissioner developing a report card rating PPOs, much like the current system which lists HMOs, available to consumers by 2009. Until then, you have a one in three chance that you are in a plan that answers to no one and that the care you receive is not ideal.

Fortunately you aren't powerless. With open enrollment, now is a good time to see if your choices whether HMO or PPO include a NCQA accredited program by going to www.ncqa.org. If not, ask your human resources department to consider one for next year. Take the same amount of time and diligence you would do researching for your next car. It's your money. Don't you deserve the best care possible? With buying a car, if you purchase a lemon, you always have another chance to get another one. With your health, the stakes are higher. Choose wisely. The information is available. Act on it. Next year tens of thousands won't be around to rectify their mistake. Make sure it isn't you.

Breast Cancer and Colon Cancer Treatment and Survivorship Guides -- A Good Idea

The American Society of Clinical Oncologists (ASCO) last month announced that they would have suggested treatment plans and summaries for breast cancer and colon cancer care as well as a survivorship plan available on their website. The former is for oncologists and the latter is for their patients. The treatment plan and summary, which consists of two pages will help oncologists summarize and review important clinical information and well as pre and post chemotherapy information to make it easier to deliver care. These forms were not intended to replace the usual detailed medical documentation, history taking, physical examination, and assessments that oncologists already were accustomed to doing.

While it remains to be seen how doctors will feel about the treatment plan and summary forms, breast cancer as well as colon cancer patients will like the one page survivorship plan. Treatment of cancer is already a complicated and potentially confusing process with many different treatments, dates treatments are given, and when the various office visits and follow-up tests are needed. The survivorship plan provides a basic road map so that an individual patient will have a basic idea of what to expect over the next few weeks, months, and years. It was recommended that the details of the plan should be tailored to the individual's unique circumstances.

This initial effort is a step in the right direction. With doctors busier and more rushed than in the past and patients faced not only with the emotional impact of coping with cancer as well as the logistical challenges of getting treatment, these forms provide a starting point of conversation between oncologists and patients. Already ASCO is working on developing treatment summary plans and survivorship plans for other cancers.

If you or a loved one has been recently diagnosed with breast cancer or colon cancer, download the relevant survivorship plan (and even the treatment plan and summary form) and bring it to your oncologist. It can only help you navigate through what is often a trying and confusing time.

Healthcare Reform Essentials

As doctors, we don’t lose sight of the most critical elements, the ABCs, airway, breathing, and circulation, in an emergency. With healthcare reform, focusing on the essentials can clarify what would otherwise be a confusing situation. Improving our healthcare system will require the following issues be recognized and addressed.

We are not getting the most value out of our healthcare dollars. Repeatedly we spend the most per capita than any other industrialized country in the world and have the worst outcomes. A recent 2007 report by the National Committee for Quality Assurance found that 75,000 insured Americans died prematurely because they did not get level of care observed in the top performing health plans. Had they been enrolled, they would be alive today. If we continue to fund a system that rewards mediocrity we will have failed. We should reward those hospitals, doctor groups, and insurers, that already consistently deliver the right care at the right time and support others to improve quickly.

Our healthcare system’s financial incentives need to change. The number of primary care physicians is inadequate to meet future demand. Current and future retirees are living longer than a generation ago and also developing more chronic illnesses. At the same time, fewer graduates wish to pursue this specialty due to high medical school loans and lower reimbursement compared to specialists. Doctors get paid to perform procedures and not to think or provide counsel which disadvantages the primary care specialties. In 2003, of those resident physicians completing a three-year residency program only 27 percent planned to be internists, down sharply from 54 percent in 1998. Studies have shown that countries, healthcare organizations, and individuals who mainly rely on primary care physicians do better with less expense.

Everyone must be required to have healthcare insurance. The fundamental truth about insurance is that everyone needs to take on the responsibility for the minority who are at risk for an adverse outcome. If health insurance was not mandatory, individuals would simply jump in when expensive medical care was needed (i.e. pregnancy, cancer) and leave when the situation improved. Healthcare costs would increase exponentially. Preventing this adverse selection will mean everyone must pay into the system.

Healthcare isn't cheap. In fact, many Americans have discovered that health costs are the leading cause of personal bankruptcy. Yet odds are very good that you will. The American Cancer Society predicts that a man has a 1 in 2 chance and a woman a 1 in 3 chance of developing a cancer sometime during his or her lifetime. This calculation excludes patients with the more common forms of skin cancer like basal cell cancer and squamous cell cancer. Remember cancer is America’s second leading cause of death. Expect to need doctors and hospitals sometime in the future.

Finally, don’t let the government run healthcare. A single payer solution would put the healthcare delivery system at the mercy of political whims and the budget process. Would you like to be hospitalized only to discover that the federal budget and the funds used to provide your care were being debated or traded for other programs the President and Congress felt to be more important for their constituents and agenda? Instead, the government should provide incentives to those whom the market would not normally enroll, guarantee insurability, set up a large insurance pool or trust to benefit from the economies of scale, and assist those who need help and who don’t currently qualify for the Medicare and Medicaid programs.

This checklist of important issues, while far from comprehensive, distills the debate into key elements that are vital for healthcare reform. To be successful we will need those who provide care to do deliver care more consistently and regularly to that of recommended guidelines, a deliberate rebuilding of our insufficient primary care workforce, require an individual mandate for all Americans, and elect government leaders who support the insured marketplace to that provides coverage for all. We know what to do. We must act quickly. Without these important and essential interventions, we are simply allowing our critically ill healthcare system to slowly wither away on life support.

Antibiotics, Dentists, and You

Earlier this year the American Heart Association changed its guidelines on which patients would require antibiotics prior to a dental procedure. Last revised in 1997, these recommendations were established to provide guidance on what antibiotics to use and which patients were at risk to developing an infection of the heart valve which is known as endocarditis.

Endocarditis, fortunately, is a rare but serious infection. It occurs when bacteria enter the blood stream and deposit on to a heart valve causing damage. Bacteria enter the bloodstream via intravenous drug use but also can occur, but uncommonly, through medical procedures as well as dental procedures. Once present, bacteria can then to spread to different parts of the body causing further organ damage. If severe enough, surgery is required to replace the diseased valve. Treatment is usually intravenous antibiotics for many weeks.

The current recommendations for endocarditis prevention will mean fewer individuals will need antibiotics.

Individuals recommended to still take antibiotics prior to dental work include those with:

• A prosthetic heart valve.
• A history of previous endocarditis.
  
• A history of congenital heart disease (check with your doctor on the specifics).
• Individuals who received a heart transplantation with heart valvular disease.

If you previously took antibiotics routinely prior to any dental work, there is a good chance you won’t need to any more. Check with your dentist and doctor. Research has shown that it often take years for newly announced guidelines or beneficial research results to become commonplace and practiced routinely. You might have an opportunity to gently educate them. The Council on Scientific Affairs of the American Dental Association also endorsed the new guidelines so your dentists should be aware as well.

Routine Annual Physical - Not Worth the Time or Money

A recent article in the September 24th issue of Archives of Internal Medicine found that routine annual physicals may not be particularly useful. Although these types of visits account for 1 in 12 doctor office visits, the study found:

• only 19.9 percent of eight preventive services were provided at these examinations as opposed to other types of physician visits.
• only 8.8% of weight reduction counseling occurred during these visits.
• obtaining mammograms, checking for cholesterol, and recommending patients quit smoking occurred at more than half of these encounters.
• individuals in the Northeast 60 percent more likely to receive a routine physical than those in the West. (Note a recent study in Health Affairs also found that health care costs per capita were higher in the Northeast).

"We need to question encouraging everybody to come in for an annual physical," Dr. Ateev Mehrotra of the University of Pittsburgh School of Medicine and the RAND Corp., who led the study, said in a telephone interview.

"There's a lot of money, a lot of visits, a lot of adults going to see their doctor for annual physical exams with a real unclear benefit. It's the No. 1 reason adults see their doctor, and yet we don't know whether it's helpful or not," he added.

This is hardly a surprise. The value of having a routine physical is no more beneficial in finding problems than having your mechanic check your car, which runs completely fine, annually just in case. For decades, there has been no scientific evidence that an annual physical helps save lives. For those who are otherwise healthy, don't take prescription medications regularly for high blood pressure, diabetes, cholesterol, asthma, emphysema, or other potentially serious medical problems, there isn't much gained from a "check-up".

That should not, however, mean that individuals should avoid doctors either. Like you car which has a maintenance light which indicates servicing is required, patients must have tests that screen for various medical problems and cancers based on the age and gender of the patient. For example, all women without a family history of breast cancer should have a mammogram starting at age 40 and repeat every one to two years. While this screening could be done during an annual physical, the screening could be done at any other future visit. The study showed that many of these preventive interventions occurred at other office encounters.

Find out what tests you are due for at the U.S. Preventive Services Task Force. It is a good start, but not the final word. Check out other organizations like the American Cancer Society, the American Heart Association, and the American Diabetes Association as well.

If having an annual physical helps remind you that certain tests should be done to stay well then continue the practice. Otherwise, save your time and money. Figure out what tests you do need depending on your age and then get them done - no routine annual physical necessary.

Enough Flu Vaccination to Go Around - Just Do It

The Centers for Disease Control announced that for the 2007 - 2008 flu season, there are plenty of vaccinations to go around. According to CDC:

Every year, flu infects up to 20 percent of the population, causes the hospitalization of 200,000 people and kills 36,000.

People 65 and older are most likely to get vaccinated, 69 percent during the 2005-2006 flu season, the latest count available.

But that's still well under the national goal of vaccinating 90 percent of seniors — even though Medicare provides flu shots for free.

Just over a third of 50- to 64-year-olds are getting vaccinated, and just 30 percent of high-risk younger adults, CDC found.

The vaccine is recommended for anyone over 50 or under 5; people of any age who have asthma, heart disease, weakened immune systems or other chronic illnesses; and pregnant women.

From personal experience this past season, I diagnosed more confirmed flu cases that in the past. The impact of flu vaccination became clear when I examined one patient, in his late 30s who was vaccinated, feel well in a day or two despite having the flu and then saw others in their early 20s, who weren't vaccinated, feel miserable, bed bound, and wanting to die (they didn't of course). On follow-up, the latter group all without hesitation planned on getting the flu shot this fall.

Perhaps you should to, especially if you are a health care provider.

American Cancer Society Launches Healthcare Access Campaign

Perhaps a sign of how dire our healthcare system has become that the most prominent cancer awareness advocate, the American Cancer Society, now needs to involve itself with healthcare reform in order to be successful with its mission.

American Cancer Society officials launched what they described as an "unprecedented" campaign Monday to encourage a national debate about access to healthcare in the United States.

"We are here today to declare that lack of access to timely and adequate healthcare has become a major cancer killer in America," said John R. Seffrin, PhD, chief executive officer of the American Cancer Society. "Far too many Americans do not have access to cancer prevention, early detection, and treatment services that we know and have proven save lives."

Doctor, Retire the Prescription Pad and the Pen

A few months ago, a coalition of companies including Google, Cisco, Allscripts, Aetna, Wellpoint, among others formed an internet based electronic prescribing system. Known as ERx Now, it provides physicians, who register, the benefits of electronic prescribing for free. Benefits include a drug-to-drug interaction check, a check to see if you have an allergy to the prescribed medication, whether the medication is on your insurance formulary or if a generic equivalent is available.

Since the prescription is sent electronically to any pharmacy, you wouldn't have to drop off a prescription and wait for it to be filled or wonder when your doctor would call in the prescription. As long as he had internet access, a complete prescription could be written in the exam room. By the time you reached the pharmacy, it would be ready to go. No wait. No worries. Illegibility is not a problem.

It is a surprising fairly robust program given the fact that it is free. Physicians can access their patient's information, allergies, and medication information, past and present.

As someone who has been electronic prescribing for a couple of years, the ability to provide even safer care with automatic drug interaction and allergy checking, the ease of refilling prescriptions at a click of a button, and the option of accessing critical patient information anywhere there is an internet connection, allows me to deliver better care.

In the past, physicians could argue that installing systems that allowed electronic prescribing, among other features, was simply too expensive. Now, with this free internet program, there is NO excuse not to adopt this practice. The only reason your doctor could justify not getting rid of his prescription pad is if he (a) never heard about this program or (b) doesn't have a computer and/or internet connection. Even then, does that trump your safety?

Open Enrollment - Picking Health Insurance As If Your Life Depended On It

It's that time again, and every year I dread this activity almost as much as April 15, or trying to find my wife the "perfect" Christmas gift. Typically, autumn is open-enrollment time for choosing a health-insurance plan. Though we gripe about increasing out-of-pocket costs, for most of us, health insurance is a hassle, a formality and not worthy of much attention.

But we could be dead wrong. Unlike other products and services we purchase, health insurance makes it difficult for consumers to adequately determine whether it is worth their hard-earned dollars. As a result, many of us chose the plans based on cost or whether our doctors participate in the plan. This ignorance could cost you your life.

The National Committee of Quality Assurance estimated that in 2005, 83, 000 Americans (nearly twice the number who died of breast-cancer) died prematurely -- because the simple things like controlling high blood pressure, lowering cholesterol and managing diabetes to levels recommended by the American Heart Association or the American Diabetes Association were not done.

The performance gap between the top 10 percent of health plans with the national average on measures like breast-cancer screening, advising patients to quit smoking, immunization rates for flu shots, exceeded 20 percent. For the airline industry, banking, and manufacturing, the quality gap was less than 1 percent. Would you be worried about flying if you knew the safety performance between the best and average was 20 percent. When it comes to health care, consumers erroneously assume that all health plans are created equal.

An additional frightening fact is that only 25 percent of all insured Americans have health plans that voluntarily provided their performance data for review by the NCQA . Only this recently have PPOs (preferred provider organizations) started to submit their performance on these basic, yet important preventive measures. It is possible that you still have a chance of not knowing whether you're choosing a poor-quality health plan this year.

What can you do? You aren't completely powerless. First, check out the NCQA website and see if your health-plan options are accredited and approved by NCQA for providing high-quality health care. If not, consider talking to your human resources department and getting NCQA accredited programs on your roster next year. It's your money. Don't you deserve the best value and quality?

Next, take charge of your health now, get the overdue preventive screening tests done, and work with your doctor on getting the right treatment, not necessarily the newest.

Finally, do the boring but simple stuff: Get control of your blood pressure, lose weight, lower your cholesterol and stay active. These interventions really do save lives. With hard work and some luck, you might just be around long enough to see an American health-care system that is known not as the most expensive, but the best at promoting a healthy and productive quality of life for us all.

Concierge Medicine - Not Worth the Money

Recently the article First-Class Health Care -- For a Price caught my attention. It talked about the practice of boutique or concierge medicine, that is hiring a doctor on an annual retainer which would be in addition to health care insurance premiums as a way of providing better care. One of the converts was quoted as "Fifty to 75 percent of known preventive measures don't get done. This boils down to one thing -- time."

What the article failed to mention is that throughout this country there are already healthcare organizations and medical providers that do consistently get the preventive measures done at very high levels. The National Committee for Quality Assurance, which evaluates health insurance plans, estimated that in 2005, as many as 83,000 Americans died prematurely not because of hospital errors, misdiagnoses, or negligence, but because they did not get care in accordance with guidelines from national expert committees, and they did not get the care backed by scientific evidence and research. In high quality health plans, simple factors like controlling high blood pressure, lowering cholesterol, and managing diabetes to the recommended levels get done and needless hospitalizations and deaths are averted.

Our healthcare crisis is not helped with concierge medicine practices. These are far from being a patch for an ailing system. There is NO evidence that the care provided by concierge medicine physicians is better than existing care. One could argue that will a much smaller number of patients and decreased breadth of practice the clinical skills of these doctors could deteriorate.

There is evidence, however, that within our country there are amazing healthcare organizations and medical providers delivering first-class healthcare consistently that does not require an annual retainer. More and more medical providers are offering same day appointments, not forced or double booked appointments, as well as the ability to email them, retrieve lab results, order medication refills, and book appointments on-line.

The real trick is Americans must reward these organizations and medical groups by seeking and demanding to have these options available to them. By patronizing these exceptional performers the same way we use other consumer goods and services will real change and better healthcare occur in this country.

NY Times Letter - Sending Back the Doctor's Bill

My letter to the New York Times editor.

Dear NY Times:

I was very troubled by the suggestion that physicians "give up some of their autonomy" by moving to a salaried system or that as a whole are overpaid in "Sending Back the Doctor's Bill" (NYT July 29th). The problem is that the current method of payment is flawed. Let me be clear, I don't blame physicians for the way they deliver care. If I was compensated the same way most physicians are, I would expect much of my autonomy to be given up and my clinical judgment clouded as I worried about which tests, diagnoses, and procedures, I needed to do to stay financially solvent rather than what the patient needed done to stay well.

This has already occurred. Our nation is the worst compared to other industrialized nations on three aspects of health care. We have the highest health care cost per capita, we have the worst in health care outcomes, and we have millions uninsured.

Instead of re-inventing the wheel our leaders should look to already successful and proven health care delivery systems and programs which exist in our country and adopt their methods.

Fortune - Andy Grove's Answer to Fixing the Healthcare Crisis

My letter to Fortune magazine responding to Andy Grove, the former CEO of Intel, and his thoughts on how to fix America's health care crisis.

Dear FORTUNE:

As a practicing family physician, I found that what Mr. Grove's and many health care reform proposals fail to address is the shrinking supply of primary care physicians. Annually fewer U.S. medical school graduates choose to practice either family or internal medicine, yet demand for these providers increases as Americans live longer with more complex and chronic medical conditions. Countries with a robust primary care workforce not only improve the overall health of the population but also do so at a much lower cost by coordinating care, minimizing duplication of services, and intervening to prevent illness. Without addressing this problem, the prognosis is clear and grim. More Americans will suffer from expensive medical complications that were unaddressed and avoidable. I am thankful that I have the knowledge and expertise on how to stay healthy. The question is will you?

Banning Pharmaceutical Representatives

It was encouraging to learn that the Hospital at the University of Pennsylvania (HUP), started prohibiting its physicians from accepting gifts from pharmaceutical companies. HUP
joined a growing list of academic programs like Yale and Stanford as well as the integrated healthcare organization Kaiser Permanente in establishing such a policy. With these types of programs in place, patients can feel much more confident that the medications their doctors prescribed are the most appropriate for their needs.

Healthcare Reform Needs IT support

In 2006, the New England Journal of Medicine published a study that found regardless of an individual's socioeconomic, demographics, and health care insurance status that uniformly Americans only received the recommended medical care just a little more than half the time. Slightly better than a coin flip. Perhaps more concerning is what was not said, - our nation does not have the desire or the plan to overhaul and implement the "large-scale, system-wide changes" to our dysfunctional health care system needed to provide quality health care to all.

Two-thirds of Americans currently rate the health care system as fair or poor. Fewer employers are offering health care insurance to their workers and retirees due to unstoppable increases in premiums. Instead of improving the system, the federal government and health care insurers major focus is the active promotion of health savings accounts and consumer driven health plans with high deductibles. By not insulating patients from the actual costs of care, it is hoped that market forces will slow costs and improve quality as patients also become consumers.

But gains in health care quality will not be driven by an informed public. Unlike other goods and services consumers compare routinely, evaluating medical care is not easy. In a system requiring more patient responsibility, a survey found two-thirds of Americans would still simply follow the advice of their physicians rather than researching the options. Yet the vast majority of patients get their care by physicians who need to rely on and sort through paper charts trying desperately to find the information they need to give the right intervention and do so only 55% of the time. Annually it is estimated that 83,000 Americans died simply because they did not receive the recommended care.

The good news is that there already are a few health care organizations and medical groups that consistently provide their patients the recommended care. Organizations like the National Committee of Quality Assurance and the Leapfrog Group continue to identify providers, health plans, and hospitals that perform at this high level. Unfortunately these groups are more the exception than the rule.

One of these high performers is the Veterans Administration. In a study published two years ago, the VA performed as well and at times better than the best commercial health plans in diabetes care. This was not always the case. The VA's recent success was due a leadership change that focused relentlessly on delivering quality care and provided its physicians the information technology infrastructure and tools to not only collect, evaluate, and improve their patient care, but to do that repeatedly and routinely across all VA medical centers.

It is clear then that the path to improve health care quality is not shifting more costs to the patients, nor is it going to be solved by requiring employers and the government to spend more money on a health care system that cannot deliver on its potential.

Unless the public and our leaders demand a complete system overhaul, the rapid implementation information technology support systems to help all providers focus on health care quality, our current and future generations cannot and should not expect to live healthier and longer than their predecessors. This is not a prediction. As it stands, this is our legacy to our children. This is their destiny.