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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Best Health Insurance - Can Save Your Life

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

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

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

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

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

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

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

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

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

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

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

Will you make the same mistake this year?

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

Abraham Verghese - The Top Gun of American Medicine

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

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

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

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

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

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


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

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

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

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

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

How to Pick Good Health Insurance - Your Life Depends on It.

Unless your doctor is a policy expert, in healthcare administration, a researcher, an author or blogger, I seriously doubt he will be reviewing an important report card that helps you pick the best health insurance plan that keeps you healthy.  Published annually by the National Committee for Quality Assurance (NCQA), this year's report card ranks 227 health plans across the country on their ability to keep you healthy and well, treat you quickly, and how patients feel about their insurance coverage.

Because unlike banking or airlines where there is not much difference in ATM machines or planes, there is a big difference in whether a health insurance plan helps in keeping its enrollees healthy.  Do children get their vaccinations?  Do healthy mothers get screened for breast cancer or cervical cancer with mammograms and pap smears respectively?  Do kids only get antibiotics appropriately for strep throat and not overtreated and unnecessarily when they have a viral illness or cold?  Are adults over 50 screened for colon cancer (something Dr. Oz can relate to).

You are incredibly busy living life.  Your health plan should proactively works with you and remind you to do the right thing?  It also helps doctors do the right thing.   

The NCQA report has been part of the US News and World Report best health plans over the past few years and will now be incorporated as part of Consumer Reports.

Be smart.  Be wise this year.  Trying to pick a health insurance plan seems easy.  They are all the same, right?  Simply look at the price.

No.

This is different.

This isn't auto insurance.  This is your health.  You want the best.  Choose wisely because your life and those of your family depend on it.

Health Reform - Explained Simply - from Kaiser Family Foundation

A brief 9 minute animation that accurately depicts the new healthcare reform legislation.

Do I Need Cholesterol Medication? Is My Cholesterol High? The Simple Truth.

The New York Times recently ran a piece that wondered if doctors were treating patients with cholesterol lowering medication unnecessarily because a web-based calculator over estimated a person's risk.  The program was proudly sponsored by the pharmaceutical roundtable and was available at the American Heart Association.

The implication was obvious. Simple tool determines an individual's risk for heart attack or death from heart attack.  It over estimates risk.  Patients treated unnecessarily.  To be also clear, the program did underestimate risk as well.


Unfortunately, the article missed an important point.  While the simplified calculator may not be as accurate as the more complex algorithm used by the National Cholesterol Education Program, the truth is doctors are likely to be overtreating patients not because the former program is presented by the pharmaceutical roundtable, but for another reason.

In my experience, doctors don't use any web-based tool.  Instead they use a simple rule - is the cholesterol over 200, which is even less precise than the vilified web calculator.

This is rather disappointing, yet occurs too often.

The public has been told erroneously that if your cholesterol is over 200 that it is bad.  Understandably to generate public awareness, a simple number is far easier to act on than the messier nuances determined by the Framingham heart study.  This classic and famous study found that total cholesterol and HDL (good) cholesterol, the age, gender, smoking status, blood pressure, and whether a person is taking blood pressure medication could provide an estimate of an individuals chance of having a heart attack or dying of one over the next 10 years.  In other words, it isn't just the cholesterol in isolation that predicts heart disease, but the profile of the whole person that does.


As a result of these calculations, some basic guidelines appeared.  Patient with a risk of greater than 20% over the next 10 years should be on cholesterol lowering medications like the "statins". Those with a risk of 10% or less should simply work on dietary changes, maintaining a healthy weight, and exercise.  Those between 10 and 20% should also adopt lifestyle changes and consider cholesterol lowering medication.

The decision tree is now far more sophisticated than simply treating a total cholesterol of over 200 with medication.

So when patients join my practice, particularly those who do not have high blood pressure, diabetes, or a history of heart disease, and who are on medication to lower cholesterol, I do this calculation with them.  Shockingly, many don't need medication. The only exception is patients with diabetes or heart disease where cholesterol lowering medication is a must. 


Though these patients are pleased, they are also somewhat reluctant.  Everyone else they know is on cholesterol lowering medication.  Bucking peer pressure, even when scientifically grounded, can be incredibly difficult.  It goes to show how powerful and effective the public service announcements have been to generate awareness.  It also shows how difficult it is to fight a perception, even when it is wrong, particularly when other doctors for expedience sake give patients what they think they want rather than what they need.  (Ever gotten antibiotics for a cold or viral illness instead of reassurance and TLC?)


So if your doctor tells you that you need cholesterol lowering medication, ask him how he reached that conclusion.  He might be doing a simple mental shortcut rather than taking a few minutes to determine your risk.  Ask him if he can quantify your risk over the next 10 years.  If you hasn't an idea what you are talking about,then ask him to Google "10 year risk calculator" to find the right test.

If you don't have diabetes or a history of heart disease and you do discover with a calculation that cholesterol lowering medication is prudent, the good news is there are a few excellent generic medications available to do the job.


Just don't ask for Lipitor the most widely prescribed cholesterol lowering medication.  It's very powerful yet most people don't need that level of potency to protect themselves from heart attack.  It's expensive as it isn't generic yet (Lipitor aka ATORVASTATIN went generic in 2012).  You probably will do just fine with the generic version of Zocor, simvastatin.  Don't take my word for it; that is the conclusion by medical experts for Consumer Reports.  If you are already on cholesterol lowering medication, don't stop until you check with your doctor to make sure it is safe to do so.


Remember, it isn't what you think you want; it's what you need.  Marketing of Lipitor or public service announcements about cholesterol can shape what you think you want.  Talking candidly with your doctor may actually help you determine what you need. Not only might this save you money, but also prevent you from being unnecessarily overtreated.