Tuesday, September 29, 2009

NutureShock - New Thinking About Children

I could not put down this fascinating book on the latest research regarding child development. What we've been told has been wrong. Chapters include - The Inverse Power of Praise - Sure, he's special. But new research suggests if you tell him that, you'll ruin him. It's a neurological fact. Another chapter - Why Kids Lie - We may treasure honesty, but the research is clear. Most classic strategies to promote truthfulness just encourage kids to be better liars.

A very shocking chapter - The Search for Intelligent Life in Kindergarten - Millions of kids are competing for seats in gifted programs and private schools. Admission officers say it's an art: new science says they're wrong, 73% of the time.

An easy read full of stunning and thought provoking research it will make you think hard about how you raise and interact with your children. A must addition for any parent's bookshelf.

Friday, September 25, 2009

Evidence That Doctors Will Not Support Healthcare Reform

While doctors are interested in covering all Americans with health insurance, universal coverage alone will not resolve the healthcare crisis. One of the major cost drivers in healthcare is due to more imaging tests, use of expensive medications, as well as more medical interventions which actually don't result in better outcomes.

This has been well described in various articles and books.

Despite our perception as physicians, it isn't necessarily defensive medicine and ordering more tests, procedures, and imaging that is driving overall healthcare costs, but is the reimbursement system. It rewards volume over quality and is particularly true for specialties that can increase volume. This is why primary care doctors have not seen increases in compensation and medical students are flocking to other specialties like dermatology, radiology, ophthalmology, among others. Primary care doctors can only increase volume by seeing more patients. Other specialties can improve compensation and volume by doing more surgeries and procedures, which in many instances are questionable if they are truly needed, effective, or even better than non-invasive treatment or watchful observation.

So it comes as no surprise that the New England Journal of Medicine's article - Physician's Beliefs and U.S. Health Care Reform - A National Survey finds doctors agree in abstract with universal coverage, but when asked to make that happen by asking themselves which expensive treatments really work and which are unnecessary that they walk away from the responsibility. Excerpts from the article:

Although physicians tend to agree in the abstract that health care resources should be distributed fairly, they may be unwilling to endorse concrete policies that expand coverage for basic health care by limiting reimbursement for costly interventions. And despite widespread discussions about using cost-effectiveness data or comparative-effectiveness research to guide clinical decisions, physicians may remain skeptical about such practices.3,4 Thus, physicians may not be willing to take on the role that the President and health policy advocates want them to play.

...surgeons, procedural specialists, and those in nonclinical specialties were all significantly less likely than primary care providers to favor reform that expands access to basic health care by reducing reimbursement for expensive drugs and procedures...

First, the President, lawmakers, and reform advocates can vigorously engage physicians in deliberations on health care reform, cognizant that most physicians see it as part of their professional responsibility. However, more controversial elements of reform, such as limiting reimbursement under Medicare (i.e., expanding the ranks of the underinsured), using cost-effectiveness data in treatment decisions, and limiting reimbursements for expensive drugs and procedures — all of which are elements of current reform proposals — may face serious opposition from segments of the medical profession.
In other words, you can't have your cake and eat it too. If we as a nation wish to expand coverage so that it is universal and everyone has health insurance, then we can't have every test, procedure, medication, and intervention that we want. However, that really isn't the right way to look at solving the problem.

The right question to ask is do we as a nation need every expensive test, procedure, medication, and intervention when others that are less costly but just as good work (comparative-effectiveness research - think Penicillin is still used for strep throat and has been around for over 60 years)? If we agree on the latter, then the problem becomes those medical specialties that benefit from more volume will see a pay cut.

When the abstract of universal coverage meets the reality of taking money away from someone's pocketbook, in this case more specialty doctors than primary care doctors, expect the discussion to become vocal and talk to elevate about rationing care rather than providing rational care. Healthcare reform does NOT require rationing.

Monday, September 21, 2009

Zoster / Shingles Vaccine - Is it Necessary?

I often get questions about the zoster or shingles vaccine known as ZOSTAVAX. Shingles or zoster is the painful skin condition that typically occurs in older patients and is caused by the chickenpox virus. If you've ever had chickenpox, then you are at risk for developing shingles later in life.

Typical symptoms initially include painful area for a few days which may be related to viral like symptoms of muscle aches, low grade fever, and malaise. The painful area usually is on one side of the body (unilateral) and along a dermatome, a nerve distribution root. The pain can be excruciating and often described as burning and intense. Patients often do not like any clothing to touch the area.

After the pain appears, a few days later a small rash of clear small blisters, known as vesicles, erupted and are typically grouped together on a base of redness. The rash appears on the exact same area of the pain.

The vesicles eventually scab over and over a period of a few weeks and resolve. The pain typically goes away as well but can take longer.

However, in some patients, the pain continues and can be irritating enough that it interferes with people's lives. This condition is known as post-herpetic neuralgia (PHN) and is more common in individuals aged 60 and older and who have other chronic illnesses like diabetes.

This is why many patients are worried about shingles / zoster. A friend has suffered from PHN and has made sure everyone they know get the vaccine to decrease the risk of developing shingles and then potentially PHN.

So how good in the vaccine? Should you get it? How common is shingles?

It depends.

From the vaccine insert of ZOSTAVAX

The rate of getting zoster is WITHOUT the vaccine:
10.8 per 1000 people per year - aged 60 -69
11.4 per 1000 people per year - age 70-79
12.2 per 1000 people per year - age 80 and older.

This means about 1 percent of the population aged 60 and up will develop shingles annually.

The rate of getting zoster is with the vaccine
3.9 per 1000 people per year - aged 60 -69
6.7 per 1000 people per year - age 70-79
9.9 per 1000 people per year - age 80 and older.

Note the decrease of those developing shingles age 60 to 69, but that the vaccine's ability to prevent shingles diminishes. This isn't due to the vaccine per se, but the immune system's ability to mount a response. As we get older, the immune system is less effective.

As a result the vaccine effectiveness is as follows:

Effectiveness of Zoster vaccine is
64% for pt aged 60-69
41% pt age 70-79, and
18% for those 80 and older.

Also from the package insert although the vaccine did decrease the rate of PHN due to decreasing cases of shingles, other complications of shingles like zoster around the eye, pain, and scarring from the rash were unchanged.

ZOSTAVAX is only indicated for people 60 years and older. Some patients cannot get the vaccine so check with your doctor.

It is covered under Medicare Part D.

More at the CDC website.

Sunday, September 13, 2009

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

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

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

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

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

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

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

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

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

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

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

So, in healthcare what do people really want?

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

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

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

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

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

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

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

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

Thursday, September 10, 2009

President Obama's Address to Congress and the American Public

President Obama showed a clear understanding of the problems in the current healthcare system. To reform it will require political leadership to outline the goals and physician leadership among others to make it happen. The real question is whether either group is up to the task.

If either group fails, then America will simply have a nation less healthy, costing more, and unable to compete in a global marketplace. In the meantime, what will we do (as well as those millions underinsured or uninsured) between now and implementation in 2013?

In other words, over the next three years each of us will still need to navigate a healthcare system that increasingly is expensive bankrupting businesses and families without making us healthier compared to other industrialized companies that pay far less.

Even with reform, it will still take years for the reality of a healthcare system that is the envy of the world to take hold. What will each of us do between now and then to ensure that we stay healthy, live longer, and spend wisely?

The President's speech in its entirety.

Tuesday, September 8, 2009

Fear of H1N1 Flu Vaccine. Theories Why.

I'm hearing plenty of concerns from patients, particularly older patients, about the H1N1 flu vaccine. Some staff also seemed concerned.

Why? I have some theories.

The speed of developing the vaccine seems by many to have been rushed. Instead of being impressed that a novel influenza virus could be identified, sequenced, and subsequently developed into a vaccine seemed to escaped many. Does anyone remember the SARS / avian flu virus that caused problems in Asia a few years ago? No vaccine was developed as far as I know. When we watch and read about stories online and have no personal experience with the flu, then we become detached from the reality. It can't happen to me mentality.

I suspect that when faced with a choice of possibly getting a pandemic virus verus the reality of getting a real novel vaccine now and whatever problems it may or may not have (and really the vaccine should be as safe as previous flu vaccines), people not surprisingly are uneasy about rolling up their sleeves for the latter.

I would also suggest that the same type of denial occurs with other preventive measures like screening for cancer and is why many people don't get mammograms for breast cancer screening or flexible sigmoidoscopies / colonoscopies for colon cancer screening. People would rather wait until they have symptoms and then deal with the consequence, even if they are life threatening and when medical science often has no answers.

As for the H1N1 vaccine, clinical trials are already occurring in Australia which is in the middle of flu season. Safety data will come out eventually but probably not in time to allow people to truly have informed consent. It is expected that the H1N1 vaccine will be available in October.

Almost no one worried about the H1N1 uses the paralyzing condition - Guillian Barre as a reason for skipping the vaccine. Gullian Barre is a legitamate concern as a few hundred cases occurred in 1976 when a flu epidemic occurred at the Fort Dix military base. CDC found since then that the risk of Guillian Barre is small (about 1 in 1 million are potentially at risk), but there has been no strong link between flu vaccine and the condition.

Recommendations by CDC suggest that those who need H1N1 vaccination are individuals age 24 years old and younger down to 6 months old, caregivers watching children 6 months and younger, as well as those ages 25 to 65 years old who have chronic illnesses and pregnant women. Many of my older patients don't wish to have the vaccine do so on altruistic grounds, which I find rather amazing in a society where the current generation seems more focused on "me" rather than "we".

While it is true that people 65 years and older who are otherwise healthy don't the H1N1 vaccine, patients don't necessarily appear relieved when I tell them this. They seem more skeptical that the science shows they are at least risk.

I don't blame them. For years we tell those who are vulnerable, typically those who are younger and those who are older, to get vaccinated. (Recall that when there was a flu vaccine shortage a few years ago due to a manufacturing problem that President George W. Bush was on television urging Americans who were otherwise healthy to skip the shot as he was). Now, we are saying "over 65 and healthy? Don't need the H1N1 vaccine". Though my patients don't appeared to be swayed about allegations of "death panels" and rationing of medical care based on age which have appeared with the healthcare reform debate, one could understandably be suspicious about the H1N1 recommendations and the absence of including the elderly.

What to do?

At least get the typical seasonal flu vaccine which is available now (local grocery stores have it). The flu kills 36,000 Americans annually.

Think about getting the H1N1 vaccine if you are supposed to. The process of producing the vaccine is similar to that of prior vaccines. It has been more difficult to produce and as a result it requires two shots rather than one.

Still on the fence? Talk to your doctor. Check out the CDC's website for the latest information.

Monday, September 7, 2009

The Dr. Oz Show - Just What the Doctor Ordered. Not a Moment Too Soon!

Dr. Mehmet Oz, cardiothoracic surgeon at Columbia, noted author of multiple best-selling books, as well as guest on the Oprah, who dubbed him "America's Doctor" has his own television show.

And not a moment too soon.

His focus has been educating the public in preventive health and wellness. With Dr. Michael Roizen, Chief Wellness Officer of the Cleveland Clinic, founder of Real Age, as well as co-author with Dr. Oz, they have made getting healthy a mission. In a country where obesity is unfortunately becoming the norm rather than the exception and where everyone seems to expect solutions for illness and stress to come from the outside through medical interventions and medications rather than from within, Dr. Oz's insight via his guest appearances on Oprah, his radio show on XM, as well as the many articles he pens, provides a major breath of fresh air.

The boring and unsexy stuff of exercising, eating well, maintaining a healthy weight, as well as focus on mental wellness really works. In a frantic world with 24/7 news cycles and instant gratification, this perspective is sorely needed particularly in our country where we are the unhappiest and certainly one of the unhealthiest among industrialized countries.

Dr. Oz is frankly brilliant. Not only did he graduate from the University of Pennsylvania School of Medicine as well as the Wharton School of Business, (of which yours truly is an alumnus), but also Dr. Oz holds a number of patents, practices and preaches the power of complementary medicine, and makes any medical topic understandable, entertaining, and memorable to the general public. As a practicing primary care doctor, I'm amazed how effortlessly he makes the complex simple. It's a sign of a true mastery of the variety of subjects he comments one and a skill that only the best teachers and professors possess.

His stage presence will make the show ultimately successful as he tackles what a potentially ho-hum topic, preventive health. Our society that favors 30 second soundbites and sensationalism and rewards media for providing this. Yet, we know in medicine that prevention works. Unfortunately no one in this country pays for this kind of intervention or advice. Medical students are flocking to specialties like dermatology, ophthalmology, anethesiology, and radiology for these reasons and shunning primary care specialties like internal medicine and family medicine. Our healthcare system reimburses for fixing problems not for preventing them. His zen-like calm, candor, and thoughfulness, as well as his ability to not be shy or embarrassed about even the most sensitive topics will make his show a mainstay of many households.

Despite this traits, however, Dr. Oz, still a significant uphill battle in making Americans healthier and better stewards for their well-being. The food industry has make what we eat more tasty, convenient, and less healthful than the foods generations ago once had. Households are stressed more than ever with higher expectations and perceived needs to keep up with the Jones as well as a fear that the American dream is being lost to other countries and foreigners who seem to work even harder for less. Children seem to stripped of childhood sooner and regimented into programs early in life so they can get ahead. Can Dr. Oz make his message heard?

A sign of a good doctor and one aspect I particularly like about him is that he will call people out. Honest, but tough. In one show, he admonished someone for not purchasing health insurance. Sure it is increasingly unaffordable and the nation must reform the healthcare system, but Dr. Oz's point was that the individual chose to spend money on plenty of other things that were not essential. Health is important and something too many of us take for granted until something happens. Dr. Oz has and continues to demonstrate that there are many things we can do to maximize our chances to stay healthy or even improve health.

Although I think he's great, I don't always agree with what Dr. Oz has to say. It's probably because he is so smart that what he touts won't been known for decades to come and that individuals like myself can't see that far ahead. (I truly believe that to be a good possibility). For example, on a previous Oprah show he had recommended that people get a testing for biochemical markers to help them determine their health. Cost? About two thousand dollars! Scientific evidence? None that I know of. Yet, Dr. Oz felt that this was important for people to have it done and Oprah recommended it as well. As a result, I suspect quite a few people spent some serious money for blood work. (A nice treadmill and a couple pair of sneakers could probably have a better health benefit for the same price). He may know more than the rest of us, so give him the benefit of the doubt, but with a little skepticism at times. I hope as he gets people to work on being healthier he balances that with the reality of increasing financial hardship. If people need to spend a lot of money to get healthier, then many will be left out.

Nevertheless, the nation needs a doctor who will speak up, make preventive health fun, entertaining, and memorable. As he noted in an article with the Associated Press:

"I found myself going to work and taking care of people who wanted to get better who believed that their only path to salvation was through my scalpel," he said. "I can heal with steel. I know how to do that. But it's very disenfranchising when you realize the true solutions are outside the operating room."

Yes, the solutions to America's healthcare system crisis is in preventive health and should be in the hands of individuals and families. Can Dr. Oz alter the perception in this country that more is better? Can he show that answer to good health isn't more imaging tests, blood work, medications, and surgeries, but the unsexy stuff that not enough of us do like eat healthy foods and stay physically and mentally active? Perhaps Dr. Oz can inspire a generation of Americans to take care of their health and a generation of medical students to commit to the primary care specialties. With a healthcare system in crisis and the current generation of children expected to be the first not to live as long as the generation before, what this country needs is a hero and a leader who boldly and wisely can get the message out that preventive health is important, cool, and most importantly accessible to all who wish to try.

I for one hopes he succeeds and suspect he will do so as he has proven time and time again brillantly.

Friday, September 4, 2009

Did you pass out? Felt dizzy? What you don't say can cost you.

A recent article in the Archives of Internal Medicine titled, "Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients" found that patients 65 years and older are often given unnecessary tests to determine episodes of syncope which is defined as "sudden, transient loss of consciousness with spontaneous recovery". Researchers found that although the vast majority of patients received EKGs (99 percent) , were admitted to hospital beds with continuous heart monitoring (95 percent), and a significant number (63 percent) received CT scans of the head, these tools only provided doctors to the correct diagnosis 2% of the time. The results of these tests only changed their medical decisions about 5% of the time.

A far better tool was simply checking the patient's postural blood pressure. This means checking the blood pressure of a person laying down and standing up and noticing if there is a difference between the heart rates and blood pressures. This simple procedure which can be performed by doctors, nurses, or medical assistants resulted in diagnosing the correct cause of the syncope in 15% to 21% of cases, which is up to 10 times better than the fancy expensive tests listed previously. This simple procedure changed what doctors did in 18 to 26% of the time, which is 5 times better.

Unfortunately, this relatively simple and inexpensive procedure was only done 38% of the time.

What is particularly disturbing isn't these findings, but rather the fact that this is been known for 20 years. As the authors note:

Perhaps the finding in this study that causes the most concern is the extent to which unhelpful, and presumably unnecessary, testing in the evaluation of syncope continues to be performed despite the compelling evidence against the practice dating back 20 years. The current study complements earlier work by showing the high costs associated with this unnecessary testing. Extrapolating our results nationally, assuming approximately 460 000 hospitalizations per year for syncope, yearly costs associated with the most commonly obtained tests may be nearly $6 billion. Investigators have shown that easy availability of low-risk testing contributes to the overuse of resources. The frequency of syncope and wide availability of low-risk testing make its an important source of revenue for hospitals. Unnecessary testing is a substantial contributor to rising health care costs and has been proposed as a target for cost savings.

So what other tools might doctors use if the expensive tests don't provide clues in the vast majority of cases? It's the secret that good doctors know. It's the secret that medical students are taught even today. It's something you should know.

Getting a good history and doing a good physical exam is far better in determining which tests are the right tests to get to the right diagnosis.

Therefore in the case of syncope, be sure to try to provide your doctors all of the information you can think of. Provide them the FOUR W's, which are reviewed in my book. In brief, they are the what, the where, the when, and the why. If you don't, then it is very likely you'll have lots of tests, told that they are all normal, and you won't get an answer of what is wrong. With increasing out of pocket costs, can you afford to pay for unnecessary expensive tests especially if they don't get you the right answer in 98% of cases?

As this study shows and what good doctors know are that what you say about your symptoms are far more helpful to get the right diagnosis and right treatment than ordering a battery of tests.


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