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

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

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

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

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

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

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

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

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

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

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

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

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


The Newsweek article concludes -

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

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

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

Why This Primary Care Doctor Loves his Electronic Health Record

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality.  The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one.  Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes?  Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators.  First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied.  Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007).  The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality.  Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections.  As most people know already, there is not typically an appropriate antibiotic to use for a virus.  It's a virus.  It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky.  In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to.  CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time.  It is a safety net.  Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done.  Indeed, to get into medical school, one has to be self-motivated, persistent, and determined.  Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors.  CDS frees up time and mental energy.  I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia.  Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen. 

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding.  I'm a big believer in the history and physical exam and how the use of HIT can make care more personal.  Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen.  Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.


Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate.  It might also be, however, our training and tradition which limits us from improving.  If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better.  We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist.  Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better.   HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before.  In the end, that is what patients really want.

This is why I love my EHR so much.

The Decision Tree: How Smarter Choices Lead to Better Health - Really?

An article in Wired magazine called the "The Decision Tree" really got me thinking. In the book excerpt, the writer suggests that patients can get to the best decision using a simple tool, a flow chart. Making a good choice relies on the following:

• inputs - data that might affect our health
• process - an action we can take to change our outcome
• decision - a question that nudges us to make deliberate choices and
• end result - the consequence of the decision process

Certainly with the explosion of medical information and the ability to access that information quickly and easily because of the internet, anyone can read up and educate himself on the latest scientific research. A simple flowchart is a reasonable structure to organize a plethora of information so that it is usable and actionable.

What troubled me, however, was the implicit message that simply taking tests, like genetic testing for a fee, or getting a wealth of medical data and then using a decision tree could result in patients choosing the right care for themselves. The internet has allowed individuals to no longer rely on experts to book plane tickets or manage our investments. The author seems to suggest that in healthcare we've reached the time that patients can empower themselves in a similar manner.

[We’re at a moment] when more data than ever lies within ready reach. Whether it’s personal genomics services like 23andMe or screening tests or self-tracking iPhone apps, each of us can draw on a wealth of personalized data sources that turn generic medical advice into customized health equations. And this is always-on data: Instead of checking in on our health episodically — when we visit the doctor or get lab test results — we can now tap into a constant stream of information and opportunity. We can minimize our uncertainty and maximize our control. We can build ever more sophisticated, and useful, decision trees.

If it was really that simple. There are significant nuances between the theoretical and practical, especially when it comes to genetic testing, which in many instances has not yet been proven to be an accurate predictor about one's future health. To understand the nuances take the simple routine cholesterol test. You already know to eat healthy, exercise, and maintain a healthy weight to achieve a lower cholesterol. Your question is whether your total cholesterol of 280 and a HDL (good cholesterol) of 35 is a problem? Do you need to take a cholesterol lowering medication?

The answer depends.

If the patient is a 40 year old man, who smokes, and otherwise healthy with a blood pressure of 120, then his risk of a heart attack is 21 percent over the next decade.

If the patient is the same man, but a non-smoker, his risk now is 5 percent over the same time of ten years.

If he is a non-smoker, but taking medication to maintain his blood pressure at 120, his risk for heart attack becomes slightly higher at 6 percent.

For the first example, the first thing the person should do is to quit smoking. The risk of heart attack drops by 75 percent. If he refuses, then his doctor should recommend starting a cholesterol lowering medication as well as suggesting taking an aspirin daily. In the last two examples, the risk is small enough that diet and exercise alone are adequate. Would a flowsheet have captured this difference in outcome?

While a decision tree and flowchart can be helpful and it is likely doctors are using a similar algorithm in our heads, the issue is who is interpreting the information. A flowchart for a critical health care decision may get the patient an end result. In situations where newer tests and technologies are involved, a review with a doctor who has the experience and expertise, will provide the framework for a candid discussion and a great result.

If this article demonstrated anything then it is that we as doctors have consistently failed to take the medical information available, interpret, translate, and then communicate clearly the risks, benefits, and choices personalized for an individual person. We can and must do better.

Choosing a Good Physician

As a practicing family doctor, it's easy for me to figure out how to choose a great doctor. Let me tell you the secrets in finding the best one for you and what I tell my family and friends.

Look for the following:

Board certification
Report card on quality
Licensing / public reporting

As a doctor, I know many doctors who have great bedside manner but aren't particularly reliable in getting the right medical care you deserve and these traits separate the so-so doctors from the truly excellent ones.

If you've found one that meets all of the criteria and you know is in in your insurance plan, has convenient office hours and easy access, then I'll give some tips on what to look for to determine if she has excellent bedside manner.

Importance of Board Certification
Your physician should be board certified in his field of expertise. Think of it as the difference between hiring a certified public accountant (CPA) and someone who just files taxes for you. While you might get the same result, if difficult issues come up, you may not get the best advice. Given how much we are all paying for medical care, why would you opt for someone who wasn’t board certified?

To carry this distinction, your doctor must have graduated from an accredited residency program as well as passed the passed the governing board’s certification exam. The examination may be a one-day or two-day written test. Depending on the medical specialty, test takers may also need to take an oral examination.

To maintain their board certification, physicians are required to devote a certain number of hours per year to additional medical education. Doctors often fulfill this requirement by attending conferences and seminars. In addition, doctors must re-certify with a repeat examination every few years to continue their status. Given all of these requirements, a board-certified doctor will often provide the most up-to-date medical care. Ensure that your doctor is board certified. As a recent article noted, doctors most likely to provide the wrong medical care for colon cancer screening were doctors who were NOT board certified.

Your physician may display his board certificate in the office. Some certificates may not have an expiration date because in the past, physicians only needed to take the exam once. It was good for life. This is no longer true. Current graduates can expect to retake the exam every seven to ten years.

Learn more and research your doctor at the American Board of Medical Specialties.


Report Card on Quality.
Find out if your doctor is practicing the latest most up to date medical care by checking out his report card on quality. Is he doing the right things to keep you healthy?

For example, unfortunately in the United States patients who have suffered a heart attack get drastically different care and many don’t get the life saving medication they need to prevent a future event. Less than 50 percent of heart attack patients in Mississippi receive this medication known as a beta blocker. Yet in Massachusetts, nearly every heart attack patient is taking it. This failure to prescribe the medication simply was whether the doctor consistently followed the guidelines established by the American Heart Association. It wasn’t whether the patient could afford the medication since all the patients received the same insurance, Medicare.

A review of 20,000 patients from 12 metropolitan areas showed that 24 percent of breast cancer patients, 27 percent of pre-natal patients, 31 percent of low back pain patients, 32 percent of coronary heart disease patients, and 35 percent of high blood pressure patients did NOT receive the recommended care developed by expert medical committees.

If your doctor isn’t doing the right things that experts recommend, then what else is he doing wrong?

See if your doctor has applied for the NCQA quality recognition designation in any of the following programs - Physician Practice Connections, Heart/Stroke, Diabetes, or Back Pain. This designation is like the Good Housekeeping Seal of Approval. To have this distinction, doctors must show the National Committee of Quality Assurance (NCQA) that they are doing the right things.

You can only use these aspect on primary care doctors (except for the physician practice connections which can be any doctor), like family doctors or internists, as other doctors don't typically participate in these medical problems or illnesses.


Licensing / public reporting
Although your physician does not need to be board certified to practice medicine, he does need to be licensed. Find your own state medical board by going to the Federation of State Medical Boards or simply Google your state (like Connecticut) and medical board.

Each state provides different public information about its doctors. This typically includes the name of the physician, his license number, when the license was issued, and when it expires. Other states provide additional information like history of malpractice suits, felony convictions, or disciplinary action by the medical board. Some states split up the licensing and disciplinary functions into two different departments or websites. While at the state website, look for a link either for physician profile or credential search.

California State Medical Board
New York State Medical Board


The first three items, board-certification, report card on quality, and licensing / public reporting I know is unlikely things you would have come up with.


Bedside Manner
So now that you've found doctors that fulfill these basic requirements, what really is important for all of us is our doctors' bedside manner. If you have friends who are medical assistants, nurses, or others in healthcare, ask for recommendations. Often they see us when we are the most stressed. If they like working with us, then it is likely that they will recommend us.

Not sure you got the best? Here is how you know.

Does she...
Sit down?
Listen?
Know your medical history?
Involve you in the decision making process or get your perspective?
Ask you – do you have any other questions?

Finally, most importantly, does she always wash her hands?

Follow this advice and feel extremely confident that you have a great doctor!

Can Price Shopping Improve Health Care? Do Pigs Fly?

In a recent Time magazine article Could Price Shopping Could Costs and Improve Health Care, the author suggests as many others have done in the past that forcing patients to more like customers and comparison shop will drive healthcare costs down.

Nothing could be further from the truth.

The theory of consumer driven healthcare goes that if there was more information about the costs of doctors, hospitals, imaging tests, and procedures that people would hunt around to find the best deal, stimulate competition, and drive pricing downward.

Proponents always point to the example of how LASIK eye surgeries have gotten less expensive because of price transparency and increased competition as more eye doctors enter the market in what used to be a very expensive procedure.

But that is always the only example that they give.

They fail to demonstrate how price transparency alone results in decreased costs. Look at elective plastic surgery, which like the LASIK example, has doctors providing a service which isn't medically necessary. Shop around. Get pricing. Has plastic surgery gotten less expensive like LASIK surgery? Of course not. Why?

In the past, LASIK eye surgery required the very skilled hands of an ophthalmologist. Over many years, however, understanding precisely who made a good candidate and the optimal surgical technique to be used become more clear. Consequently the procedure became standardized. As a result, these days LASIK surgery is typically performed by an machine that is essentially automated under the supervision of an ophthalmologist. Because of this standardization and precision, LASIK surgeries are done more reliably and quickly for those who are good candidates. For those of us who have conditions that don't fit into this neat workflow, we will still need to rely on the human doctor's expertise and experience. In those situations, the pricing won't be inexpensive.

It isn't price transparency alone that will drive costs down, but the standardization of treatments for a particular ailment. Specific treatments for bladder infections (urinary tract infections), sore throat, like strep throat or mono, pink eye (conjunctivitis) are fairly clear cut and straight forward. This is why walk-in clinics like Minute Clinic can drive costs downward using less expensive physician assistants and nurse practitioners, rather than doctors. For sore throat, the workflow is pretty obvious (and available at www.familydoctors.org).

Note how they avoid back pain and chest pain. It may be for liability issues, but also because the amount of precision needed isn't quite there. Once medical science can determine which tests or interventions can reliably differentiate a symptom or problem into a specific treatment will costs come down. This is probably why plastic surgery won't quite ever become a commodity like LASIK surgery. How would you like to have a standardized nose job or face lift?

Proponents of consumer driven healthcare also believe that having patients pay more of their healthcare expensive or "having more skin in the game", will also drive costs down over the long-term. The thinking goes that if people understood the high costs of having a chronic illness like diabetes or heart disease that they would choose healthy behaviors. They should appreciate that preventive interventions like cancer screenings were less expensive than dealing with a cancer diagnoses and subsequent treatment. Getting a simple vaccination to prevent influenza or pneumonia would be far better in preventing emergency room visits or hospitalizations. People would begin to make rational choices and opt for less costly therapies today to put off very expensive theoretical losses in the future.

Odds this will occur? Highly unlikely.

Simply look at how the American consumer fared when given financial responsibility to make decisions presumably for their best interest, retirement planning, to determine how successful the public might be in embarking on consumer driven healthcare.

Starting in the 1970s, employers started to shift employees from pension plans (defined benefit plans) to 401(k) plans (defined contribution plans), where employees would have more financial responsibility and have "more skin in the game" in determining how much to save and how to invest for retirement. The thinking was that employees, looking out for their best interest, would do research and demonstrate the rational behavior needed to ensure that they retired with a nest egg that suited their needs. After all, who would have more motivation to save for retirement than the individual himself?

Did it work out as planned?

A recent article from CNN Money found that 43 percent of Americans have less than $10,000 saved for retirement. More importantly "the gap between what Americans have saved and what they'd need for retirement is forcing workers to prolong their working years."

In other words, the American consumer isn't doing well to save for retirement even though it is in his best interest. At least in retirement planning, consumers have the option of delaying retirement and working longer.

Consumers as patients, however, won't have that luxury of putting off medical care if they suddenly become ill. It is very likely a large number of Americans instead of losing weight and controlling blood pressure will have a devastating heart attack that requires open heart surgery. Colon cancers will be detected at later incurable stages requiring very expensive chemotherapy for months rather than having been removed years earlier with less costly colonoscopies. It is very likely in consumer driven healthcare, much like defined contribution retirement plans, that the consumer or patient hasn't saved enough to pay for these very expensive future therapies or treatments.

As a graduate of the Wharton School of Business, however, I wouldn't do my education justice if I completely dismissed the concept of efficient markets, consumerism, and competition. If consumer driven healthcare is to work, it will require a few elements, which unfortunately the American healthcare system at this time is ill equipped to deliver on.

I will discuss these crucial elements in a future post.

Secrets to Preventing Heart Disease

I recently gave a talk to discuss how to keep the heart healthy and avoid heart disease. February is designated as heart health month. Heart disease is the leading cause of death in both men and women. Yet within our country, there are doctors who consistently treat their patients to the latest research such that for their patients, heart disease is no longer the leading cause of death! In fact, their patients chance of dying from heart disease is 30% less than those of other doctors and hospitals in the same communities.

Their secret? Knowing your numbers and then treating them. Risk factors for heart disease include the following:

Age
Gender
Cholesterol
Blood Pressure
Smoking Status

The older you are, the more likely you will have heart disease. In terms of gender, men will tend to have heart disease at an earlier age. Women will see their risk gradually increase after menopause (average age of menopause is age 51).

Cholesterol is a risk factor, but needs to be determined in the context of the above risk factors. An excellent heart risk calculator is the 10 year risk calculator. Punch in your numbers. (Patients who have diabetes or a previous history of heart disease don't use this calculator because you should already be on cholesterol lowering medications called "statins"). The calculator is from data generated from the Framingham heart study, the nation's longest heart study.

Those with < 10 % risk, continue lowering your risk by dietary changes and exercise. Those with 20% or great risk, contact your doctor immediately and find out if you should start taking cholesterol lowering medications, blood pressure medications, or quit smoking as a 1 in 5 chance of dying from a heart attack or having one is pretty high! Those between 10 to 20% should see their doctor and ask what more can they do to lower risk.

Need more? Here's the secrets to preventing heart disease courtesy of Kaiser Permanente.

Book Review - Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life

As a practicing family doctor and author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System, I am a strong believer in empowering and educating patients so that they can make the right decisions to get the most out of life. As the only doctor in my family I don't think it is fair that only the people I know or care for are privy to the truth about staying healthy, so I looked forward to reading Medical Myths That Can Kill You: And the 101 Truths That Will Save, Extend, and Improve Your Life, by Dr. Nancy Snyderman, chief medical correspondent for NBC News, which has a similar same perspective.

Overall, the book was a mixed blessing. It has interesting factoids, ideas we should all take to heart, but at times is misleading. As a consumer and a patient, I thought the truths and news you can use pieces were interesting. As a primary care doctor and patient advocate, however, I felt that many parts of the book were misleading. Perhaps one of the faults is it tries to be too ambitious and attempts to cover too many topics, which often are not in depth enough to be of much value.

Dr. Snyderman points out correctly multiple times that the path to good health is through prevention by adopting healthy habits, staying physically active, and maintaining a sensible weight. The structure of the book reflects this preventive focus and chooses to debunk many myths with these clever chapter titles - Annual Checkups Are Obsolete, Vaccinations Are Just For Kids, Doctor's Don't Play Favorites, Only Old People Get Heart Disease and Stroke, We're Losing the War on Cancer, Natural Means "Safe", and You Can Just Snap Out of Mental Illness. She tackles the truth about herbal and dietary supplements, the unproven value of full body scans, as well as the importance of vaccinations and preventive screening tests for cancer, heart disease, and diabetes.

Throughout the book there are plenty of truth tidbits including, "you cannot catch sexually transmitted diseases from toilet seats; you do not need to drink eight glasses of water every day", among many others and news you can use segments that will make some readers hopefully more aware of what is myth and what is fact. These small sidebars were very interesting. I think patients and consumers will find these factoids topics of conversation.

As a practicing doctor, however, there are many areas which are misleading and others that provide information too superficial to be of value. Dr. Snyderman is correct in one of her chapters that heart disease and stroke are the leading causes of death in this country. However, she uses two individuals, a twenty-six year old former beauty pageant winner, who suffered from a stroke, and a forty year old woman, who died suddenly from swimming, as reasons why we should be concerned. The problem is that these type of occurrences are extremely unlikely and rare for these age groups and gender. The typical cause of these problems, atherosclerosis, or hardening of the arteries didn't cause these cases. The former was most likely due to a heart wall septal defect or a blood clotting disorder, known as a hypercoagulable state. The latter was probably due to sudden cardiac death from a fatal arrhythmia, like ventricular fibrillation.

In the area of stroke, she talks about atrial fibrillation, a heart arrhythmia, as the leading cause of stroke. It is a cause, but this heart condition is typically found in patients over age 60 and far more common in people over 80 years old. She doesn't say that and one would naturally and wrongly assume based on the prior patient stories that it can happen at younger ages, which again is extremely unlikely.

Other areas that are covered superficially include when Dr. Snyderman discusses cancer and mental illness. She pushes for prevention as well as clarifies myths that still exist among the public. Unfortunately in the chapter on cancer, she also talks about various cancer treatments which isn't thorough enough and doesn't seem to fit in a book with this preventive theme. For the mental illness, one of the best written sections because of her personal experience, again the book is rather too ambitious and tries to cover anxiety, depression, and bipolar disorder and the various treatment options even as she admits that "it is impossible to go into as much detail as I would like to". Though she gives a website reference, perhaps it may have been better only to cover depression as she and her husband both had experienced it, and acknowledge the other conditions.

Overall, I wanted to like this book as I believe the intent of giving the public the facts about what they can do to stay healthy and well is vital. I think as a practicing doctor and insider, however, the book at times it is misleading, in some areas is too light in content and in others the information deviates from the book's intent of wellness and health promotion.

Newer Isn't Better. It's Unproven and Expensive.

There is a small trend among the media which is actively questioning the latest medical treatments and therapies on whether there is enough scientific evidence that would justify all of the increased costs. In an excellent piece in the NY Times titled - The Evidence Gap - Weighing the Costs of a CT Scan' Look Inside the Heart, Alex Berenson asks a simple, yet hard to answer question - is using heart CT scans worth it? The timing of the article was coincidental but was at the same time of Tim Russert's unexpected passing. Unlike many articles since Mr. Russert's death, this one asks us to think before we blindly believe that newer is better. Is there evidence-based research that says these procedures will save lives? From the article:

• Increasing use of the scans, formally known as CT angiograms, is part of a much larger trend in American medicine. A faith in innovation, often driven by financial incentives, encourages American doctors and hospitals to adopt new technologies even without proof that they work better than older techniques. Patient advocacy groups and some doctors are clamoring for such evidence. But the story of the CT angiogram is a sobering reminder of the forces that overwhelm such efforts, making it very difficult to rein in a new technology long enough to determine whether its benefits are worth its costs.
• Some medical experts say the American devotion to the newest, most expensive technology is an important reason that the United States spends much more on health care than other industrialized nations — more than $2.2 trillion in 2007, an estimated $7,500 a person, about twice the average in other countries — without providing better care.
• No one knows exactly how much money is spent on unnecessary care. But a Rand Corporation study estimated that one-third or more of the care that patients in this country receive could be of little value. If that is so, hundreds of billions of dollars each year are being wasted on superfluous treatments.

Bottom line? You and I are paying more for very expensive therapies that may not be better for us, but certainly appear cooler and sexier because they are newer. Those doctors and patients who dare to ask for proof will feel shunned. The former will be unable to make a living because the public demands these newer tests and will take their business to those who they perceive are giving them the best care even though there nothing to support that belief. The latter will feel like something is amiss even as their colleagues and friends flock towards these treatments even though it won't make a difference in their health, except for making them poorer. The pressure not to follow through is intense.

What to do? Be very skeptical. Align yourself with doctors who don't tout the latest therapies, except in the case of cancer treatment where the newest can be the difference between life and death. Seek out information. Hope that reporters like Mr. Berenson and authors like Shannon Brownlee can make their voices heard loud and clear, because it is unlikely that doctors as a group can avoid the seduction of new technologies, particularly since it drives more business and revenue.

Because if the media can't get enough of us to ask these important questions, is newer better, is it proven, you and I will simply pay more thinking we are getting better care, when in fact we are simply wasting money and getting no better care.

Tim Russert's Legacy on Heart Disease

Tim Russert's untimely death from heart disease has appeared to have many focus on decreasing their risks by quitting smoking, exercise, decreasing blood pressure and taking cholesterol lowering medications. Kudos to being unbiased in reporting that many of the fancy hi-tech scanners don't help determine whether a future heart attack is imminent. As the reporter correctly pointed out, no test is perfect.

The report also clarifies that Mr. Russert had everything humanly possible to decrease his risk from America's number one killer.

Could Tim Russert's Heart Attack Been Avoided?

Not a trivial or academic question. Time magazine identified the NBC's Meet the Press moderator and Washington bureau chief as one of the 100 most influential people in world in 2008. His loss at such a young age, 58, is tragic. His ability to make complex topics clear for the public and to ask the hard questions will be missed in this the most historic presidential races in American history.

But was his sudden passing and fatal heart attack an avoidable tragedy? His internist, Dr. Michael Newman, who is affiliated with George Washington Medical Center, noted that Mr. Russert died of a sudden coronary thrombosis, which can occur without warning. Mr. Russert had been diagnosed with asymptomatic heart disease which reportedly was well-controlled with medication and exercise. He passed a cardiac stress test in late April. It seems like he got the appropriate care.

Yet, our healthcare system only provides the right preventive care 55 percent of the time. What medical students know, lowering blood pressure, controlling cholesterol, and arranging age-appropriate cancer screenings, shown to save lives, are not done routinely in this country. The ability of doctors and insurance plans to provide this
basic fundamental care varies by about 20 percent. If one compared the safety performance of the top 10 percent of airlines with the national average, the quality gap was far less at less than 1 percent.

The National Committee for Quality Assurance (NCQA) estimates that had all doctors and insurance plans performed at the level of the nation's top 10 percent that 80,000 Americans, all who had health insurance, would have avoided premature death. That is twice the number of breast cancer deaths annually. A study of 20,000 patients in 12 US major cities found that only 68 percent of those with heart disease and only 65 percent of those with high blood pressure received the recommended care developed by expert committees.

Unfortunately, one can't assume that the best preventive care is done at university medical centers. A study in California found that the vertically integrated healthcare organization Kaiser Permanente outperformed both university medical centers and community hospitals in decreasing their patients' heart attack risk and death by 30 percent. The integrated VA healthcare system was also found to outperform community hospitals in caring for diabetics. It consistently ensured its patients got the right medications at the right dosages better that those in the communities around them.

It seems that as a country we take for granted the failings of the healthcare system which are occurring with alarming frequency. As we mourn the unexpected passing of a great journalist, we should instead ask ourselves whether there were systematic failures in the healthcare system that Mr. Russert relied on to keep him well? The goal wouldn't be to find negligence or to identify scapegoats, as like the aviation industry, the delivery of healthcare is too complex to simply isolate one person or entity that resulted in the mishap. It is very likely that General Electric, NBC's parent company, provided him with health insurance options that were accredited by NCQA as excellent in keeping people healthy.

Is it possible, however, that the recommended care wasn't delivered? As our nation struggles with how to make the healthcare system more affordable, accessible, and with higher quality, the debate boils down to who is best in determining the right care at the right time. Is the onus on patients? Does the responsibility rest on the healthcare industry? It is an important conversation our country must have and certainly would have gone better with a skilled moderator like Mr. Russert. He will be deeply missed.

Calculate Your Heart Attack Risk Now!

You can easily calculate your risk of having a heart attack or dying from a heart attack by going to the National Cholesterol Education Program's website. All you need to know is your cholesterol (total and HDL - good cholesterol), your latest blood pressure, and whether you are on medication to control blood pressure. The other information you need you should know already - your age, gender, and whether you smoke.

The number generated is your risk of having a heart attack over the next 10 (TEN) years. If your risk is 5 percent, that means if 100 people with the same risk profile, i.e. same cholesterol, blood pressure, age, gender, etc., were followed over 10 years, five of those individuals would die or suffer from a heart attack over that time. The other 95 individuals would do just fine.

The calculator should not be used for people who have diabetes or who have had a heart attack or heart disease (coronary artery disease) in the past as these individuals are already considered high risk.

While you cannot change risk factors like age or gender, other risk factors for heart disease are modifiable. Blood pressure and cholesterol can be lowered. For one thing, you can decide whether or not to smoke, and whether or not to eat well. If, after taking the test, you discover that your risk is 10 to 20 percent or 20 percent or higher, you should check with your doctor. He may suggest that diet and exercise are enough or if a cholesterol-lowering medication needs to be prescribed to further decrease your risk.

Remember that this is only a tool and is not a substitute for sound medical advice. Even if your number is low, you still need to do the right things to stay healthy. Heart disease is the leading cause of death in this country, but don't ignore the second leading cause of death, cancer, either. You should, however, review your numbers with your doctor at a future visit.

The calculation is based on the information and findings from the famous Framingham Heart Study. This research study initially started in 1948 and followed a group of over five thousand adults, ages thirty to sixty-two, with extensive physical examinations, history taking, and blood work every two years to determine risk factors and patterns for heart disease. In 1971, the study followed a similar number of the original participants’ adult children and their spouses. Though the data was based on thousands of people over a period of years, the calculation may not be entirely accurate for individuals who are non-white (the study was performed on people living in Framingham, Massachusetts, which at the time of the study was predominately Caucasian). Nevertheless, we can thank the study for our current understanding that addressing high blood pressure, high cholesterol, smoking, obesity, diabetes, and physical inactivity decreases the risk for heart disease.

When you use the calculator, you are in fact using evidence-based research to determine your risk of heart disease. See if your doctor uses the same way to determine your risk next time you see him or her.

Newer Isn't Better - Cholesterol Medication Not Effective

A report found that Merck's cholesterol lowering medication, Zetia, did not show any benefits.

While this report was surprising, it illustrates an important fact. Newer medications aren't necessarily better than previous therapies. The active ingredient in Zetia, which is also found in Vytorin, lowers cholesterol, but the released clinical trial showed that it didn't slow the clogging of arteries. This is why clinical trials need to be done to prove therapies are effective. While one can assume that lowering cholesterol can improve clogging of arteries, one needs to have proof.

If you go to the ZETIA website, there is the following disclaimer.

• Unlike some statins, ZETIA has not been shown to prevent heart disease or heart attacks.

So, when your doctor prescribes you a medication, particularly if it is one that has been heavily marketed, ask him the following.

• Why this particular medication?
• Is this one proven to save lives (i.e. lowering cholesterol isn't as important as preventing heart attacks).
• Are there others that are less expensive and proven?

Try not to ask your doctor about medications that you saw on television. Research shows that doctors more often than not will prescribe it for you.

Caveat emptor - Let the buyer beware.

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.

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.

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?