The Narrative in Medicine

It is each person's story that makes medicine an art and not only a science. Each person who seeks care, is seeking more than just a scientific approach to their particular symptom. Rather they are looking for someone to listen to their concerns, understand their life, and help them in a way that is unique to them, not only to help them in a way that is in keeping with a guideline or a standard. Often in our debate over health reform, and our focus on insurance coverage and economics we lost sight of those critical stories.

A Hopeful Trend

A good physician should therefore be a great listener. A great teacher of medicine should be someone who understands how to tell a patient's story in a way that helps developing physicians (and physicians should be developing throughout their careers) become more attuned to the particular chords in a patient's story. Historically, some of our greatest modern storytellers have been physicians. From John Keats, to Arthur Conan Doyle to 20th century authors such as William Carlos Williams, Oliver Sachs and Abraham Verghese. A number of medical journals including Health Policy, JAMA, and the Annals of Internal Medicine now have as part of their editorial policies, regular narratives that describe the doctor and patient "stories" in ways that are human, caring and understandable. That trend towards better storytelling, is one that is likely to improve medical care. But can it effect medical costs and medical quality?

The Health Savings Paradox: A Story

It turns out that when you develop health care programs that give professionals time to listen, despite what may seem like worse productivity, medical costs go down as a result. This is best demonstrated (of course) with a story that is published in last week's JAMA. In "Going Home". Dr. Anne Jacobson tells us of Maria, As Dr. Jacobson states,

"Maria, like many of my patients, had grown up and lived most of her life on a ranch in Mexico. She immigrated to the United States because her husband was coming here, and for her that meant she did not have a choice. In the stories that emerged over the years, I heard terrible tales of violence endured during the early decades of her marriage. After she left Mexico the physical abuse stopped, but her husband still controlled where she went and what she did. The two places she was allowed to go without much interference were to church and to the clinic. She visited both frequently"

Dr. Jacobson paints a picture of a woman, not only a patient. She describes how Maria's health improved because she had someone to talk to and someone who was truly interested in her story.

"Her physical symptoms began to improve, and we spent infinitely less time chasing the source of multiple complaints. For years her blood pressure and cholesterol level were not as well controlled as I would have liked, perhaps because both of us knew that something deeper was broken inside. Still, I fretted over the numbers and tried to make changes that wouldn't overwhelm her. As she started to believe in herself, she also began to believe that her body was worth taking care of. She started taking her medicines just like she did everything else—religiously. And one miraculous day, I shared her latest laboratory results with her—all exactly where they needed to be—and told her I was proud of her."

The Flip Side

The story as told by a skilled medical story teller show vividly how listening to a person's story and helping them as they take their life's journey improves care and saves money. To do that it takes time and as we try and save money in health, we often try to do that by decreasing the time physicians spend with their patients. When this happens, costs can go up or patients can try to find other reasons to see the doctor that are drive up cost and risk to the patient. In another story in JAMA published earlier in November, Dr. Nir Lipsman brings this phenomenon to life.

"Pulling the curtains aside, I saw a familiar face. We had operated on her three times in the last three months, and now she was back. "You like the food here, I guess," I conjured up somewhere from a deep and far-gone sense of humor at 3 AM. She had fallen and re-bled in her brain, and she would need another operation. We had become her family over these months; she lived alone, with her own family either dead or having abandoned her. Does anyone deserve this kind of treatment?
Am I asking about our treatment or her family's? I don't remember. I got her consent for surgery; she knew the risks and recited them from memory, always a good sign. I told her that this time we'd try to get it right, and the fleeting thought crossed my mind that maybe she fell on purpose this time."

Let's Not Lose the Narrative

As we debate health reform and deal with the problems of access to care and health care costs, we should always remember that medicine as an art requires physicians, nurse and others who can listen to patient's's unique stories. Patients are just people striving to survive and sometimes reaching for greatness in their own ways. Understanding their narrative is all about caring and not just about care. It recognizes the patient as a person rather than the simple sum of their symptoms. That is truly the art of medicine and the author physicians of our time understand and communicate that for the betterment of medicine. My hope is that any reform that is passed does not make it more difficult to hear our patient's unique stories.

Answering Questions

On the average of three times a week, I get calls from people asking my advice on issues related to health.  The requests for advice fall into two categories.  They may be about individual medical decisions such as from a family member thinking about whether to have knee surgery, an executive in a managed care company asking about home care options for a chronically ill child, or a senior executive in an unrelated industry asking about a complex issue involving an employee or even a family member.  They may also be about health policy such as the call from a businessman asking me to explain how the provisions of the current health care bill passed by the Senate may affect his business.  While many of these people have other experts they can turn to, I believe that they call me because of a number of factors.  They know that whether speaking about individuals or about matters of finance and policy, I will think about what will contribute to delivering the best health care available in a caring, efficient manner, and they also know that I will not make a decision for them but will instead help inform and support them in their decisions.  My goal is always to frame and clarify a question rather than give an answer.

My Philosophy of Medical Decision Making

Whether the question is “macro” (policy) or “micro” (individual) I approach these questions with a certain philosophy that has three major components.  The first is that is that the best medicine and the least expensive medicine is the most personal, that is it is the most customized for the particular patient in that particular situation.  The second is that everything in medicine has side effects (and often hurts) so that all decisions for evaluation and care must be made with thought.  The third and the most important is that each individual is the only true expert on themselves and therefore they are in the best position to make their own decisions.  My view is that health care is too important to be left to the sole discretion of your doctor or an insurance company.  The best model is one in which the doctor is a partner and an advisor making decisions for you only if you want him or her to do so.  The most important role of a doctor is to make the complex simple and help each individual have all the facts they need to make the right decision for themselves.  In the same way, the best insurance product, whether designed by the private marketplace or by government, is the one that makes needed care easily accessible and helps people make the right choice for themselves. 

Micro Example: Everything Hurts

I have always believed that a minor medical procedure is a procedure that someone else has.  Everything that is done to me or a family member is major.  Lest you think I am some sort of monster who only cares about myself, I believe that to be true for everyone.  An article this month in JAMA is related to this point by carefully evaluating post operative pain in woman who have had breast cancer surgery at 2 years after the surgery.  The study showed that about 50% of women had chronic pain at two years and that they had pain even with breast conserving, minimal surgery.  How many of them knew to expect that?  How many of us are truly told about the potential side effects and long term results of medicines, surgeries or even of diagnostics studies?  (Did you know that the average CT scan exposes you to more than 100X the radiation that a chest x-ray does?)   Even the simplest test can put someone at risk.  A good physician should be someone who explains the potential risks and benefits of anything you have done to you, in a way that is understandable to you. 

Macro Example: The True Expert

The debate over health care reform is partly being driven by the fear that a new program will impinge upon individual’s rights to decide (with their physicians) what the best course of therapy is.  People are afraid of losing whatever autonomy and flexibility they currently have with the new proposed legislation.   They are afraid that the new health care system that Congress may unveil will only decrease their control over their own health care decisions.  An article in the New England Journal of Medicine makes that point.  While this article states that according to polls people want health care reform, it also says “most Americans do not believe they will be better off if the current legislative proposals as a whole are enacted. Most, but not all, of the polls show that among people who see the plan as affecting them personally, more believe they will be worse off personally and in terms of the cost and quality of their care than believe they will be better off (CBS, October; NBC, October; Gallup, October).”  Thus far the political debate has not focused on whether we will be giving people more information when they need it and whether we will support the individual’s right to make their own decisions.  Instead we are caught up in political posturing on both sides of the aisle and the bill that is being produced tries to satisfy everyone by saying “yes” to everything except individual autonomy.  Until health reform recognizes the patient as their own true expert, it will be hard to achieve optimal care at the lowest cost.  In both policy and practice, I do have more faith in the public than in the “expert” legislators.

Interpreting Public Health “Facts”

As I discussed in my last blog, interpretation of medical facts is often crucial for individuals who need to decide on their own approach to care, such as in the decision whether to obtain screening mammography at age 40 or 50.  Equally important, especially with the current public debate about health care reform, is the ability to interpret public health “facts”.  A recent article in the Journal of Public Health entitled “Analysis of 23 million US hospitalizations: uninsured children have higher all-cause in-hospital mortality” illustrates how the straightforward often is not as straightforward as it seems. 

Causation and Association

The article starts out by stating in the introduction that the goal of the study is to “characterize the impact of insurance status on inpatient mortality and costs of care”.  It then, in the discussion at the end states, “we estimate that 16,787 deaths might have been prevented over this time period assuming lack of insurance was the driving factor”.  It actually gives no data to support the premise that lack of insurance was the driving factor.  The study does show that lack of insurance is associated with an increased death rate but it is important to remember that just because two things are associated does not mean that one causes the other.

For example, is it possible that people without insurance are of a lower socio-economic strata and may have more social problems?  Are there more single parents in that group?  Are there more children whose parents, due to social issues, are battling drug abuse and alcoholism and then the children are not receiving adequate care on that basis?  There are many factors that are associated with lack of insurance that suggest that the increased mortality is just as likely related to those other factors as it is to the lack of insurance.  One thing is clear and that is that this study does not tell us anything about the “impact of insurance status on inpatient mortality” and instead only tells us of the association between lack of insurance and inpatient mortality.  No causation is shown. 

Other Factors Not Addressed

In every public health study, it is often the other factors that are not addressed that are most important.  In this study, for example, the largest number of deaths above what you saw in children with insurance, occurred in the  newborn period.  The lesson I would learn from this is that there is an association between poor prenatal care and death rate for newborns as any woman who wants prenatal care can get it via public health clinics as well as urban health centers.  Women who receive prenatal care at those centers also tend to obtain Medicaid coverage or other coverage thus the newborns would also be expected to have some coverage at the time of birth.  That factor was not mentioned in the study.

Be Careful of Hidden Agendas and Biases

There is no such thing as a study totally without bias and studies can be useful even if bias is present.  However to really use a study, be sure to look at what was studied and what was stated on the basis of what was studied.  Often the topics studied have little to do with the conclusions that are drawn.  In this political environment, that is especially true.  So read the studies and be careful of the headlines.

The Mammography Controversy – Interpreting Medical “Facts”

The practice of medicine is a game of probabilities.  While often (but not always – but that is the subject of a separate discussion) based on scientific fact, those facts themselves are always dynamic and a good physician is always trying to predict the future which while based on facts is ultimately unknowable.  Will the illness get better or worse?  Will this medication or treatment make the patient improve or will the side effects and risks of the therapy actually create more problems?  Will this screening test discover an illness that can be cured or will it actually lead to further tests and therapies that are, in and of themselves, dangerous?  All of these questions are asked about future events and the unique, individual nature of each of us means that medical “facts” are sometimes not facts at all, but educated guesses based on the interpretation of studies.  Even when dealing with population wide public health issues, the “facts” from studies and from expert panels cannot be divorced from simple laws of statistics and probability and are rarely incontrovertible.  These same facts when read by different people can also be influenced by the most human of emotions and even by political desires. 

Screening Mammography

We see that in the political firestorm that has erupted over the US Preventive Services Task Force (USPSTF) recommendations that were announced this week that state that screening mammography should only be performed on women over 50 and only once every two years.  This is different from the standard recommendations which are still supported by the American Cancer Society which recommend mammography every year for all women over 40.  What made the USPSTF take this step?  Let’s look at what makes a good screening test.  Any screening test is limited by its sensitivity and specificity.  They are:

sensitivity = probability of a positive test among patients with disease

specificity = probability of a negative test among patients without disease

If a test is sensitive but not specific, you will have many false positives.  In medicine a false positive often means great anxiety in the patient and may also mean invasive procedures (such as breast biopsies and even breast surgery) which puts people at risk.  In this case the USPSTF looked at all the studies that have been done concerning screening mammography, including recent studies that specifically looked at women aged 40-50 and determined that there were enough false positives in this group that the risk of unnecessary procedures outweighed the benefit of finding a breast cancer at an early enough stage to be curable.  The American Cancer Society (ACS) and some of the other organizations that are criticizing this move are looking at the same data and coming to a different conclusion.  They acknowledge the risk but believe that the benefit outweighs the risk.  My own approach is to give all these facts to women and let them decide.  Most women are smart enough and know their own ability to handle risk well enough to take in these various recommendations and make their own decisions. 

The Insurance Effect

The difficult decision is now with the insurance carriers who must decide whether to set their benefits to encourage a yearly mammography for women over 40 or an every other year mammography for women over 50.  Most companies follow the recommendations of both the American Cancer Society and the USPSTF.  They rarely disagree and when they do, there is a definite dilemma.  My own recommendation is to pay for the test based on the ACS but only to encourage it in materials and mailings based on the USPSTF.  I believe the studies done that are cited in the new recommendations are strong and sound but I also believe that breast cancer is a disease that causes fear in families and that fear is very real.  Many women may want the reassurance of earlier and more frequent mammograms even if that means they will be increasing their risk from unnecessary tests and even potential unnecessary surgeries.  I would not make it more difficult to have those tests by creating new financial obstacles.

Costs of Coverage: Facts and Figures

As I spent some quality time reading the Affordable Health Care for America Act which just passed the House of Representative, I realized that at least some of the people who read this blog do not really know what the costs are for health insurance and how this bill may affect those costs.  This posting is therefore designed to give you, by reviewing a couple of recent studies, some real numbers so that costs can be better understood.  Unfortunately, when we debate whether to spend one trillion dollars or eight hundred billion dollars, the real numbers sometimes get lost.  Lee Trevino, one of the great golfers of our time, once, when asked about the stress of making a putt for first or second place in a tournament worth tens of thousands of dollars said, “Real pressure in golf is playing for ten dollars when you only have five dollars in your pocket”.  By the same token, talking of billions and trillions of dollars if often not as meaningful as talking of the amounts a family has to pay.  So the place to start is asking just how much an employed family now pays for health insurance.

Current Health Insurance Costs

A study published in Health Affairs reported on just that question.  Entitled, “Job-Based Health Insurance: Costs Climb At A Moderate Pace” and based on the Kaiser/HRET Survey of Employer Health Benefits the article says that average annual health premiums in 2009 were $4,824 for single coverage and $13,375 for family coverage.  Most people’s employers pay about 75 - 80% of those costs however labor economists are quick to point out that since employers calculate employee costs on the basis of salary plus all benefits, those dollars that employers pay for health premiums are really taken right out of salary checks.  Those premiums are about 5% higher than they were in 2008.  Premiums reflect the costs of medical care.  While much is made of the high administrative fees, even in the most expensive of plans, administration is still less than 20% of the premium costs (and usually less than 15%).  

Impact on Hospitals

A major part of the 80 – 85% of costs that are directly related to care are paid to hospitals.  While it might sound obvious, the amount of money a hospital will charge for a stress test, delivery of a newborn, treatment in the Emergency Room, or any other service therefore directly impacts your premium and out of pocket costs (after all everyone has that pesky deductable and the 20% or so that the individual is responsible for).  Also in Health Affairs, a study entitled “How A New ‘Public Plan’ Could Affect Hospitals’ Finances And Private Insurance Premiums” specifically assessed how the proposed public option would effect hospital bills for those who are on an employers health plan.  In the article they say “Because it is possible, and perhaps even likely, that this new public payer would pay less than private payers for the same services, such a plan could negatively affect hospital margins. Hospitals may attempt to recoup losses by shifting costs to private payers.”  That would become higher premiums for employers, higher out of pocket costs for employees and less financial room for employers to raise salaries or hire new employees. 

Large Employers Point of View

In a report published today entitled “Health Care Reform:Creating a Sustainable Health Care Marketplace” the Business Roundtable spoke of their belief that if implemented in the best possible manner, parts of the current health legislation may lower the upward trend of costs by 15 or 20%.  They also pointed out that the way the legislation is currently being discussed, the risks to achieving that sort of saving is significant.  They did go one step further and suggested that the best way to save money is to foster “true market reform” which would include individual accountability, full transparency of cost and quality information, a focus on health rather than our current focus on illness and addressing professional service capacity, that is the number of physicians, especially primary care physicians we need.  They gave Lasik surgery as an example of the effect a free market has on health costs.  Lasik is considered cosmetic and is therefore not covered by insurance.  In recent years, cost has come down for the surgery and quality has improved. 

 

As this chart show, as the number of Lasik surgeries has increased, the cost initially sent up, then decreased dramatically as more eye surgeons learned the procedure and became adept at it, and then the price became relatively stable, going up only in line with the cost of living of all items.  While cosmetic surgery is not the same as necessary care, there are ways to encourage market forces in health care.  Current legislation being considered by the House and Senate does not use those free market tools. 

The Bottom Line

Health insurance is expensive and is getting more expensive.  It reflects medical care.  Any effective plan needs to fundamentally change our system of paying doctors and hospitals, change our medical liability laws, and address individual responsibility in order to create real change.  I do not see that in any of the current proposals.

The Personal Side of H1N1

I have not written this blog for a few weeks now as I try to cope with my own bout of H1N1.  While the course is said to be brief, the truth is that it is extremely variable.  If it was always mild and brief, which is true for the majority of cases, we would not see any deaths. Tragically we are seeing deaths.  In my case, and in the case of my fifteen year old son who was generous enough to share it with me after he was infected, it was more severe.  My son’s illness went on for about five weeks and had associated with it a pneumonia on chest x-ray.  I am now at the end of my third week and while my fever and chills only lasted a few days, the cough and muscle pains and weakness that I have are persisting and only now gradually decreasing.  It has obviously impacted all aspects of my life, including the writing of this blog.  It is often easy to forget that all illness has impact beyond the illness itself.  A person who is sick, either with H1N1 or with a serious life threatening illness is a person who is living their life, going to work, taking care of the people they love and all that is impacted by the illness. 

Who Gets H1N1?

Supposedly I am in the age group that is less likely to get the infection.  However I am also a great example of the fact that even if you don’t “fit” the profile you can still get the disease.  By this age graph, since I am in the 50 – 64 age group, I should not be at high risk however it is safe to say that my risk was 100%, since I have it. 

How Do I Feel Once I Get It?

The short answer is not very well.  Fever, cough, shortness of breath and muscle pain are typical of the illness.  On a personal basis, I was lucky enough to have all of those and the cough and muscle pain (from my observation of myself and my son) take the longest to clear up.  This chart shows the common symptoms for those people who have been hospitalized for the illness, according to the CDC. 

Symptom	Number (%)
Fever	249 (93%)
Cough	223 (83%)
Shortness of Breath	145 (54%)
Fatigue/Weakness	108 (40%)
Chills	99 (37%)
Myalgias (Muscle Pains)	96 (36%)
Rhinorrhea (Runny Nose)	96 (36%)
Sore Throat	84 (31%)
Headache	83 (31%)
Vomiting	78 (29%)
Wheezing	64 (24%)
Diarrhea	64 (24%)

Looking at the Data

Every week, the CDC sends out an update on the course of H1N1 from around the country.  The most recent from yesterday, describes a picture of increasing hospitalizations, increasing deaths and widespread activity in 48 states.  However even this may be understated.  An article that was published on the Internet by researchers at the CDC and at Harvard looked at the cases of reported H1N1 and then tried to determine through mathematical models, whether that accurately reflected the number of cases that were being seen.  Their answer was stated in the article:

“Through July 2009, a total of 43,677 laboratory-confirmed cases of influenza A pandemic (H1N1) 2009 were reported in the United States, which is likely a substantial underestimate of the true number. Correcting for under-ascertainment using a multiplier model, we estimate that 1.8 million–5.7 million cases occurred, including 9,000–21,000 hospitalizations.” 

Since then, according to the CDC, the number of cases has actually increased with 17,838 hospitalizations and 672 deaths documented that are related to the H1N1 infection thus far.

What About the Vaccine?

All available data shows it works.  Get it if you can!  The problem for most people is that the vaccine is in short supply and it may also be too late for the bulk of the population.  The illness appears to be peaking now rather than later in the season as is typical for the usual seasonal flu.  Thus far, (as of Nov 5), 26 million doses have been shipped while 36 million doses are needed just for the high risk groups (and I don’t fit into that group).  The government has taken the lead in managing supply of the drug.  They have not done a stellar job however it is hard to criticize as I don’t know that it was possible to do a stellar job under these circumstances. 

Bottom Line

Try not to get sick while understanding that a large part is out of your control, unless you can become a true hermit until the epidemic is over.  If you do get sick, don’t be like me and see your doctor early to potentially take an anti-viral agent, such as Tamiflu early.  I toughed it out and should not have.  I will get back to my usually medical article review and commentary as soon as the coughing stops.

Mindfulness Medicine

One of the challenges of practicing medicine, day after day, month after month, year after year is seeing each patient at each encounter as a new and unique experience.  For the patient, who has a problem that is unique to them at that particular appointment (that is why they are there seeing the physician), they expect nothing less however they often receive a quick response from the physician, who sees a common issue which is the same as he or she has seen thousands of times before.  The danger that lurks for both physician and patient (more for the patient) is that the difference between a common harmless problem and an unusual dangerous problem is often extremely small and the physician must be open to the possibility and be actively looking for the unusual to be a good physician.  Due to a number of factors, including the financial incentives and the insurance company and government requirements, the physician is often concerned with efficiency, productivity, and compliance with regulations rather than with thoughtful evaluation of the unique person and problem sitting before them.  That leaves the patient with a doctor “going through the motions” and a doctor often unhappy with their practice. 

Mindfulness Medicine

With physicians spending less than ten minutes with a patient, and payment systems pushing more doctors away from spending time with patients, how do we encourage thoughtful evaluation of every person in every encounter with a doctor.  A term, mindfulness medicine, has been coined to describe how we want a physician to act when he or she sees a patient. A recent article in the Journal of the American Medical Association defined that term as “a quality of awareness that includes the ability to pay attention in a particular way: on purpose, in the present moment, and non-judgmentally.  Mindfulness includes the capacity for lowering one's own reactivity to challenging experiences; the ability to notice, observe, and experience bodily sensations, thoughts, and feelings even though they may be unpleasant; acting with awareness and attention (not being on autopilot); and focusing on experience, not on the labels or judgments applied to them.”  In that article, the authors described a course of study for physicians to teach them mindfulness medicine and assessed the impact on the physicians’ satisfaction with practice and found that the doctors involved gained much more satisfaction following the course of study and were also more attentive and empathetic with patients.  But what about the patients?  Was the care improved?

Reflexive versus Cognitive Care

We do know that empathetic physicians tend to listen more effectively and that should improve care.  Care today is often reflexive, that is a doctor doesn’t really think about what is unusual concerning a patient but rather hears “runny nose” and reflexively thinks upper respiratory infection, and not leaking cerebral spinal fluid from the brain.  Usually that is fine (as a doctor can go through an entire career and never see a runny nose that isn’t just a runny nose).  However if the doctor misses the unusual aspect that can make that runny nose indicative of a brain problem, that could be a deadly mistake.  In my career of trying to influence medical care through managed care techniques, my goal has always been to build programs that foster thinking, or cognitive care and try to fight reflexive care.  Doctors tend to be smart and highly trained but they are human and often have to be shaken out of complacency that comes from routine.  The trick of reminding them of their intellectual roots can be challenging, especially in view of the many forces pushing them in the opposite direction.

Mindfulness, Health Economics and Reform

In the latest issue of the New England Journal of Medicine, there is a roundtable discussion with Drs. Atul Gawande and Elliot Fisher who are both physicians and Professors Jonathan Gruber and Meredith Rosenthal who are both health economists.  All are expert in areas of health policy and the effects of payment systems on physician practice as well as expert on the details of the various iterations of the proposed health reform packages.  At one point, Dr. Fisher says “Fee for service does not pay for us to have long conversations with our patients. When we're feeling constrained, it's much harder for us to have that long conversation with a patient with heart failure to see if we can safely manage them at home. The default position in many communities becomes, "Gosh, I'm too busy. I better send them to the emergency room."  Does any version of the current health reform bill address this?  While in the published article, which leaves out parts of the conversation, this issue is not addressed, the full transcript available on the NEJM website does reveal Professor Gruber addressing it by saying, “The problem is, we’re pretty far from legislative language. And there’s not that, quite frankly, can be in a bill by October 15th or by November 15th or probably even in the next couple of years. My feeling is, as we look to this round of reform, the science of coverage has gotten so far past the science of cost control that that’s why I feel like the President, on one level, did a bit of disservice holding up cost control as such a key feature of this round of reform.” 

The Short Term Answer

Until payment systems can encourage doctors to spend time and think, rather than encourage them to act reflexively, we will need to hope that more educational programs to teach mindfulness like the one described above are put into place.  As patients (and all of us are patients at some point) we also need to demand that from our doctors every time we are at an appointment.  That means going in to an appointment prepared to ask questions and to find ways to get the doctor to think about us differently even if only for the ten minutes he or she is with us.

The Dog That Didn’t Bark

It is often pointed out that Arthur Conan Doyle’s model for the great detective Sherlock Holmes was based on the methods used by physicians to determine diagnoses.  While patients are invariably most concerned with the treatments, as the treatments will make them better, most physicians, especially family practice physicians, internists, pediatricians and ER doctors, all of whom are on the front line of medical treatment, are usually much more concerned with making a proper diagnosis as the treatment often follows the diagnosis in a very straightforward way.  Missed and incorrect diagnoses can lead to disaster and it can be a true mystery to determine the cause of an ailment or a symptom. I think about this while reading a wonderful book Every Patient Tells a Story by Lisa Sanders.  Dr. Lisa Sanders describes the challenges of making diagnoses through stories of real situations between doctors and patients.

Finding what Doesn’t Fit

I admit that I enjoy watching formulaic detective shows on television.  Give me a good episode of NCIS or Monk (prior to this season in which the writing has gone downhill) and I am happy.  As you watch these shows, you often see that the trick in finding the killer and solving the mystery, is finding the fact that does not fit with the others and persisting until a different answer can be found that does explain all the findings.  In many ways, a good diagnosis follows this approach.  You tend to start with a number of possibilities in your mind and you then test these possibilities with the patient’s history, physical exam and lab tests.  You have to know quite a bit from just the history and physical to select the right lab tests.  This is the most important part of the science and art of making a diagnosis.  One patient story comes to mind.  A young physician with severe abdominal pain comes into the Emergency Room saying that he has right sided abdominal pain that is excruciating and also has a low grade fever.  He tells the ER doctor that he thinks he has appendicitis and a surgeon comes and starts to take him straight to the Operating Room.  No one notices that he is squirming on the gurney and cannot get comfortable.  That doesn’t fit.  People with appendicitis have to hold very still to minimize their pain.  The appendicitis turns out to be a kidney stone, luckily discovered before the incision is made to operate. (I was the patient in that story some thirty years ago when I was an intern)

Solving the Mystery

It turns out that, for a physician, making a diagnosis often requires thinking about each patient in a new way and not allowing yourself to become complacent about every person having the typical illness.  Dr. Jerry Groopman has written about this in articles in the New Yorker and in a book How Doctors Think.  Dr. Groopman talks about doctor’s use of heuristics, or rules of thumb, and how it makes the physician more efficient but also may make a physician less thoughtful and therefore less accurate in making difficult diagnoses.  It takes time to carefully take a history and perform a physical examination in such a way to get to a potential list of diagnoses.  It also takes some strong presence of mind not to see twenty cases of constipation  due to poor diet and perform just as careful a history and physical on the twenty-first to discover that colon cancer while it is still treatable.  Good medicine takes time.  Yet our payment systems do not reward for this time.  Rather the payments encourage large numbers of patients seen briefly with little true “thinking” about each person seen.

The Best Diagnostician

The most impressive diagnostician that I know is my wife who sees newborns who may have rare genetic diseases.  The history that she takes can go back for generations in a family.  Her physical examination will often cause her to precisely measure the distance between the eyes and carefully describe the ear folds.  She will routinely take two hours or more to see and evaluate a new patient.  That may be why, despite her many years of training, first as a pediatrician, then as a Clinical Geneticist, and her many years of experience including running statewide programs in genetic diseases, her income is below that of a general pediatrician. 

Paying for the Best

I think about all this as we continue the health reform debate in this country.  While we debate the public option and the mandated coverage while also talking about cutting Medicare payments and eliminating a popular Medicare program (Medicare Advantage), we avoid talking about the payment reform that will actually encourage physicians to perform careful, thoughtful histories and physical exams and likely save money on procedures, tests and surgeries.  Right now, Medicare and Medicaid have the market power to initiate payment reform and encourage the type of payment system that would improve quality of care by improving the solving of medical mysteries that is the heart of diagnostics.  I only hope that someone in government wakes up to this basic need in reform.

Three Ways to Pay Physicians

This week I find my self reminiscing.  It was 1969 when the Harvard co op was formed to provide health care for Harvard employees and the employees of Harvard affiliates.  That became the Harvard Community Health Plan (HCHP) which was considered to be among the best staff model health plans in the country.  The plan paid physicians salaries and was run by physician managers who focused on quality of care and based care on the best information from medical knowledge.  Unfortunately, the wonderful care that the Harvard physicians were giving did not give consumers what they wanted.  During that golden era, a small voice in the guise of an article in the Journal of the American Medical Association appeared (1993) found that the public preferred solo and small group practices to HMOs!  How unenlightened of the public!  A larger voice, which was the Boston area marketplace, prevented HCHP from achieving market success and the plan was forced to merge with the then, Pilgrim Health Plan to become Harvard Pilgrim.  The salaried doctors were now joined to the private doctors.  That too did not last long as Harvard Pilgrim was soon forced to spin off the physician group as Harvard Vanguard after shrinking the salaried group.  That group now survives by contracting with all health plans.  It still gives excellent care and is still loved by some and shunned by others who perceive it as clinic medicine.

Back to the Future

We now return to the present day and find that the concepts underlying the HCHP model are alive and well and now being presented as a new option.  In this week’s New England Journal of Medicine (NEJM), Dr. Arnold Relman, one of the giants of medicine and a professor at Harvard Medical School for many years, advocates for accountable care organizations, run by physicians in which the physicians are paid salaries.  In Dr. Relman’s proposed model, there is competition between groups on the basis of service and quality but only one payer with each group being paid the same by government (or some other single payer entity).  The question is whether this is the HCHP without the messiness of having to compete.  If the only competition is other salaried groups of physicians run by physicians, is that really competition?  It just seems as though we are returning to the group model plan of salaried physicians that was rejected in the marketplace, except this time we are not allowing anyone to reject it.

Value in Health Care

In a different article. also from the NEJM , Dr. Denise Cortese of the Mayo Clinic collaborates with Jeffery Korsmo, to argue for measuring the value of health care and making these value measurements widely available on the Internet.  They define value as quality divided by cost. To quote the authors, “In this equation, quality includes clinical outcomes, safety, and patient-reported satisfaction, and cost encompasses the cost of care over time.”  The authors also make a good case for moving towards value based payment to health care organizations and even physicians as well.  They also prefer paying physicians salaries however they do modify it with a value equation.  To further quote the authors (quoting the philosopher Seneca), “The philosopher Seneca said, “We most often go astray on a well trodden and much frequented road.” There is a clear path to higher-quality, more affordable health care, if we are willing to veer from the familiar route. We must define value, publicly display understandable value scores, and pay for value.”

The Three Ways

There are generally believed to be three ways to pay physicians, fee for service with is our current system, capitation which pays physicians a set fee per person they care for as an enrollee in their panel, or salary.   One can think of these options as paying doctors to do more (fee for service), paying doctors to do less (capitation) or paying doctors to leave at five o’clock (salary).  Both articles are taking on payment reform which appears to be missing from the current iterations of the health reform package and should be the most important piece of any legislation.  Systems that pay for value and that make measurement widely available to the public are the most likely to be successful.   It is less important whether those value payments are as bonuses over a salary or are a modified fee for service system.  Perhaps this is the fourth way to pay physicians and one that will combine some of the best parts of our current approach. 

Belaboring the Obvious

Much of medical research is exciting and important and filled with hope for curing cancer and stopping the scourge of epidemics.  Then there is the research that has to do with what, for most, seems like the obvious.  I thought about this in the context of end of life counseling when I wrote about HR 3200, the house health reform bill.  If someone is dying, isn’t it obvious that the doctor should counsel them? Does that have to be law, with specific instructions on how to counsel a dying patient with specific options proscribed by law?  But this blog posting is not about the reform issue but instead is about new articles in the scholarly medical literature.  It is just In this month’s Journal of the American Geriatrics Society the mundane and the seemingly obvious is the topic of a number of the lead articles.  Lest you think I am just mocking these dedicated researchers in geriatrics, the older I get the more these mundane issues touch me directly.  I know these studies are important and may one day (very soon) may affect me and even you.

Someone Who Is Elderly Can Become Frail

The first two articles in the September issue have to do with deciding when someone who is elderly is also frail.  These authors from UCLA define frail to describe “older adults with low functional reserve who are vulnerable to stressor experiences and at risk for adverse health outcomes”.  (whew!)  They use a formula which includes a number of tests reflecting different body systems to indicate if someone is actually frail.  The second article written by a group in Boston from Boston University and Harvard, compared two different indexes to measure frailty.  It found that both were effective although one was simpler.  Both articles are actually important as they both challenge a disease focused approach that is embedded in the way medicine is conceptualized and the way it is practiced.  An editorial in the journal by George Kuchel at the University of Connecticut points out that the specific disease in someone who is elderly is often less important that the overall health that is implied in these different definitions of “frail”.  That too is obvious in many ways but often ignored in the practice of medicine.

Sending Elderly People Home from the Hospital Requires Planning

The third article in the journal is about a team at the Johns Hopkins Medical School who came up with a “Safe STEPS” program to help the elderly transition from the hospital to home after an acute illness.  There are some very radical approaches in this such as the physician and the pharmacist collaborating and the team having a discharge meeting to make sure everything the person needs to go home has been done.  It turns out that when you do this, those patients have fewer returns to the Emergency Room and fewer readmissions.  Isn’t that surprising.  If you think this too is obvious please note that it is very unusual to see this collaboration in care.

Advance Care Directives Have to Be Individualized

The easiest thing to do to describe the fourth article is just to quote the conclusion from this group from Yale.  They conclude that patients need “customized, stage-specific interventions based on individualized assessments to improve advance care planning”.   How radical can you get?  Patients need care, especially when they are incapacitated that is unique for them!  The study makes the point that people vary in their readiness to listen, their barriers to listening and even in the potential benefits such directives can give them.  Thus they must be approached and spoken to as individuals with specific needs and desires.

The Simple is Difficult

I could continue to go on.  Other studies in this September issue of the Journal of the American Geriatrics Society include articles about pain causing functional limitation and yoga helping spine problems.  It may all sound obvious, mundane and simple but the impact these “little” items have on health and wellbeing is often immense and the difficulty of having them done often overwhelming. 

Ethical Health Care Reform

With the publication of the Baucus proposal for health reform, we may be entering the “end game” of negotiations about a final bill.  My intent today is not to review that bill because, while I believe it is the most realistic of all proposals in play, it is unlikely to be the final agreed upon version.  Rather it seems that with its publication, we now have at least two starting points for the final push towards legislation, the Baucus bill and the House bill.  The debate has played out thus far on financial and ethical terms and there are significant ethical dilemmas to consider.   Reform of a health care system, that no matter how confusing and flawed, still gives excellent care to those in need who access the care will not be easy or straightforward.  The debate cannot, however continue to be the cartoon caricatures that each side seems compelled to present.  I believe that the ethical issues are between two positive ethical visions and not between two opposing visions, one from the devil and one from the angels (pick which is which depending on which side you are on). 

The Proposal To Kill Grandma

Obviously there is no proposal on the table to develop death panels.  However, in the White House’s own words “the President’s plan will create an independent Commission, made up of doctors and medical experts, to make recommendations to Congress each year on how to promote greater efficiency and higher quality in Medicare”.  If we follow that proposal to one potential result, it could easily include proposals to shift spending from complex cancer treatment to prenatal services.  That is certainly good and ethical.  However if you are the 80 year old who is now not getting new cancer treatment because of that shift in resources, you may not believe it is ethical towards you.  The fact is that in a classic article written in 1995, it was found that the United States statistics on survival at age 80 is the highest in the world.  Part of the reason for that is that we, in the United States have far better survival rates for cancer than anywhere else in the world including other western democracies.  We do exceptionally well in finding people with breast and prostate cancers and treating them aggressively.  That, according to statistics from the American Cancer Society.  Would that change under some of the proposals being considered?  It could.

The Un-American Racist Proposals

On the other hand, the opponents of the Presidents plan are not liars, un-American or racist on the basis of their opposition to the reform proposals.  They are honestly worried about the high financial burden to be placed and the loss of ready access to high tech, costly care if you have a cancer or other catastrophic illness.  However they also cannot just ignore the findings as outlined by the Institute of Medicine that people without insurance are less likely to get adequate care for stroke, cancer, heart disease and diabetes among other conditions. 

The Greater Good or the Individual Good

As a nation of people who believe strongly in the Horatio Alger story that stresses individual initiative and individual responsibilities and rewards, we tend to lean towards programs and policies that allows for unique decisions in health care which includes the right to get whatever care they and their doctor believe to be appropriate for their individual predicament.  The greater good, from both a population health and a financial health point of view may involve limiting that individual decision making to some extent.  Many of the proposals currently on the table can take us down that path.  That is either a reason for celebration or a reason for caution.  Does the ethics support allowing that person to get the care that they and their physician deem to give them the best chance of life, even if the odds are low, or does the ethics support a process to determine on a population basis that, if the odds are low, the resources should be spent elsewhere.  The answer will require balance and careful discussion, not demonizing the opposition.

Lowering Health Care Costs: The Answer

The elephant in the room of the health care reform debate is how to add 30 million people to the health insurance roles while also decreasing health care costs.  The best way to start this discussion is to state the obvious which is that health care costs are a product of the unit price of a service or product (such as an office visit, a surgery, a medication or a splint for an injury) multiplied by the number of services.  We already know that with an additional 30 million people joining the health insurance roles, that the volume of services will have to increase.  We also know that the current proposals on the table do not address unit costs.  While proposals have been put on the table to change the government formulas for calculating provider payments, they have not been included in the current versions of health reform now being proposed.  In testimony to Congress on September 15, 2009, Dr. J. James Rohack, President of the AMA stated, “We are pleased that the new target growth rates proposed in the House legislation are not limited to GDP growth”  In other words unit price will not, by these proposed statues, be controlled.  So if we can’t or won’t limit volume of services and we can’t or won’t limit the unit costs, what can we do to lower total costs?  The esteemed journal Health Affairs recently took this on with their Sept/October issue entitled “Bending the Cost Curve”.  The articles in the issue, and also the academic discussions usually revolve around three foci of cost control strategies. 

It’s the Price Stupid! 

One particular article, written by Jonathan  Oberlander and Joseph White in the Health Affairs issue make the strong case that our unit costs are just too high.  They use data comparing the volume of services in other countries that have much lower costs and find little difference with the volume of services in the United States.  They go on to show that our costly payments to physician specialists and for high tech and invasive procedures are the main contributors to high health care costs.  In a separate article in the same issue, Bruce Vladeck and Thomas Rice state that these high unit costs are due to a “lack of power on the purchasing side” meaning that insurance companies and government are virtually helpless to negotiate with physicians and hospitals as the providers of care have a monopoly of sorts and there is no cost sensitivity to their services.  They suggest that only a monopsony which is a situation in which there is a single purchaser of a particular service in a market (great SAT word for my fifteen year old) can solve this and the best monopsony to fight their monopoly is a single payer system.  Of course I do question why this tough negotiating cannot go on now as Medicare and Medicaid pay one third of all health care in the United States. 

Lower the Volume!

While the articles I have just cited minimize the effects of efforts to lower the utilization of services in favor lowering unit costs, other articles do acknowledge that lowering the “waste” in the system can lower costs while potentially improving quality. In an article by Arnold Milstein and Elizabeth Gilbertson, they cite studies by the Institute of Medicine and the Congressional Budget Office that show, “30–40 percent of US health spending is waste which primarily encompass services of no discernable value (the CBO’s focus) and the inefficient production of valuable services (the IOM’s focus)”.  In their article and in other articles in that issue, specific programs that have successfully lowered the volume of services (and by so doing lowered costs) by focusing on eliminating services with little to no value, are highlighted. 

Blame the Patients!

The third focus targets consumer or patient issues that are largely driven by culture in America.  Although that is addressed only peripherally in Health Affairs, other authors have written extensively on social and cultural influencers having major impact on costs including direct to consumer advertising for prescription medications and celebrity activities and endorsements.  It is often said that Al Roker’s obesity surgery led to a plethora of such obesity surgeries, many of which were unnecessary and inappropriate.    A classic book on this topic, Medicine and Culture written by Lynn Payer remains an excellent review of this topic.  Ms. Payer goes into great detail on the American culture being one that values technology and aggressive interventions and our health systems and payment systems reflect that cultural bias.

My Answer

In many ways my answer is the obvious one.  There is no easy answer.  There are important bits of wisdom in all of these articles yet none of them give us a simple roadmap of how to save money while maintaining or even improving the quality of care.  We will need to change the culture to some extent.  We will need to develop new payment systems to lower unit prices and we need to encourage programs such as the ones in Health Affairs that are shown to work to eliminate utilization of services that provide no value in final outcome to patients.  Only by a combined approach are we likely to have success.  Unfortunately, I do not see any reform bill that thoughtfully does all this. 

Three Speeches on Health Reform

I admit that I did not listen to President’s Obama speech before Congress. I wanted to be able to understand his proposal and his arguments without the pomp, circumstance, standing ovations and partisan spins that are integral to such occasions. Instead I waited a couple of days and then sat down to read the text of the speech. To my surprise, I actually say three different speeches incorporated into one speaking session. They were intertwined so it may not have been readily apparent. This is, however, what I saw as I read the speech and confirmed when I read the President’s proposal on the White House web site.

Speech Number 1: The Problem and the Proposal

A major part of the speech was a recitation of the problems that are necessitating action. The fear of bankruptcy for those with catastrophic illness, the problem of being denied coverage for pre-existing conditions, the challenge for those without insurance were all outlined with skill and passion. The President’s high level proposal was largely agreeable to a cross section of Congress and the American people. The president stated, “And there is agreement in this chamber on about 80 percent of what needs to be done.” There is a large part of the President’s proposal which is seen in both Republicans and Democrat proposals. We could pass a law tomorrow if the President and Congress would just take that 80% and pass the legislation and we would have improved the system appreciably with a relatively simple agreement that eliminates pre-existing condition clauses, guarantees insurability and eliminates some of the insurance rules that create barriers to care. Even the insurance carriers support that because they will still have the level playing field and will potentially have more customers. On the White House web site, the President’s proposal is now posted and spells out some of those “significant details” that the President alluded to in the speech that are part of the 20% of which differences remain. Thus he clearly states in the White House proposal “Offers a public health insurance option to provide the uninsured who can’t find affordable coverage with a real choice”. There is little agreement on that public option which seems like it will be modeled on Medicare. Medicare which is now extremely costly to taxpayers, inefficient and largely unpopular with physicians as the payments tend to be lower than they receive from negotiated contracts with private insurers. This is the same Medicare which now offers “waste and inefficiency” which we can somehow mine for the money to pay for the proposal, but more on that in a moment. While there is little sympathy among the public for physician incomes, the fact is that we are not, as a society, able to increase the number of primary care physicians in the United States partly because the Medicare fee schedules for those health professionals falls far short of where they should be.

Speech Number 2: Demonizing the Opposition and the Insurance Companies

President Obama, intermixed his definition of the problems and his solution with a strong targeting of those who disagree with him and with the insurance companies. “Instead of honest debate, we've seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and counter-charges, confusion has reigned.” Actually I have seen a lot of honest debate which the President has chosen to call scare tactics. In a wonderful column in the New York Times, Max Blumenthal quoted Eisenhower as saying, “In a democracy, debate is the breath of life.” We have seen a lot of debate and I still hope that the debate continues. In the end, it will result in a better law being passed. Yet the demonization of those who disagree is troubling. Unfortunately that demonization is strongly emanating from the While House and the Congress.

Speech Number 3: Show Me the Money

The third speech was how to pay for it. I must admit that I did not follow this very well and each time I re-read it, I still don’t understand. It seems like the centerpiece is an independent panel of physicians to suggest ways to eliminate waste and inefficiency. The nature of medical care is very personal and it has always been difficult to lower costs through the simple elimination of waste and inefficiency as one man’s waste is another’s necessity. While I know better than most of the the waste in the system as I have dedicated my professional life to finding ways to decrease cost, improve access and improve care, I also know that having a panel of independent physicians will solve nothing and will not make money appear magically. Covering 30 million people who are now not covered is not free and is not paid for by finding waste. Without comprehensive payment reform of the type that is not seen in any bill, we will just be working around the margins. In a previous blog I discussed the fragmented way physicians are paid and pointed out that the fragmentation leads to higher costs. There is nothing in the proposal to change our payment systems. An Article by Fuchs written back in May (which seems like a lifetime ago in this debate) states “A government insurance company is no substitute for real reform” yet that, and a physician panel, appears to be the drivers of lower costs in this speech and proposal. Forgive me if that just makes no sense to me.

What Happens Next

I do believe that a bill will be passed and that we will be moving into uncharted waters. I only hope it doesn’t cause more harm than good. None of us can know for sure how this will evolve and where we will go. In a future blog, I will discuss my thoughts on lowering costs and improving access while improving care.

Association versus Causality

I find it fascinating to read reports in the newspapers of new advances in medicine and new insights into medical care.  I try to find the hidden, or not so hidden, mistakes or misinterpretations that often occur.  In a previous blog, I wrote about reports of basic research that are years away from practical use that give the impression that therapies are immediately changing in response to the research.  Today I get to discuss another common error.  Proving an association between two different illnesses or conditions and implying that there is a causal relationship that can impact treatment when one may or may not exist. Let’s get specific:

Depression and Heart Disease

It has been known for many years that people who are depressed are more likely to get heart attacks.  In a study this past week in the Archives of General Psychiatry, it was shown that people who have already had a heart attack, have a doubling of mortality after the heart attack if they have major depression.  This article was the basis of a news article in the Wall Street Journal which asked the right question in its title “Will Depression Treat Heart Disease?”  Based on the results of this study, should the medical profession be more aggressive in treating people for depression after heart attacks?  Should cardiologists and others who treat these patients be trained in screening people after heart attacks for depression and treating them with appropriate medications and therapies?  What about the risks of using those medications on people after heart attacks?  There are risks especially in people who are known to have heart disease.  It almost seems obvious that if people with depression after heart attack have a double risk of dying, that we should be as aggressive as possible in identifying and treating depression in people with heart disease.  However it may not be as obvious as seems.

Does Depression Cause Death in Heart Disease or Does Bad Heart Disease Make You Depressed (or neither) 

That is the major real question here.  We know from the study that I cited that there is an association between heart attacks, depression and death but we don’t know whether one causes the other and which causes which.  Two recent editorials in the Sept 1 issue of the Journal of the American College of Cardiology commented on this.  One article pointed out that there was no evidence that screening for depression actually improved the outcomes of coronary heart disease.  The other, while agreeing with that fact took the position that identifying depression was good in anyone so it should be done.  While we know that depression, heart disease and death are associated, we don’t really know how best to use that knowledge to help people.  We don’t know if the heart disease is causing the depression in which case treating the heart disease more successfully might improve the depression, or if the depression is worsening the heart disease in which case we would want to identify and treat the depression in order to improve the heart disease.  Of course the increased mortality with depression may just be due to the fact that the depressed people are not taking their medications and doing their cardiac rehabilitation.  Maybe all we need to do is improve the way we give medications and encourage people to exercise and not deal directly with the depression at all.

Have I Confused You Yet?

In some ways I hope so.  Not because I want to frustrate all of you but because I do hope to show you that even an easy straightforward association may not imply a straightforward therapeutic direction.  We all want simple answers however even when the facts are simple, the answers they imply may not be. 

Various “Factoids” from Medical Journals

Those of you who have read my blog and who have read other past efforts I have made to make medicine understandable know that I tend to follow three themes in these writings.  One is understanding health policy and the impact health care has on economics and policy, the second is bringing understanding of the care function of health that must be delivered hand in hand with the scientific aspect and lastly reporting on the new science which is published on an almost daily basis.  Ultimately, these three aspects must come together in a caring health care system that is based on sound science and is supported by valid economics.  In this posting I want to focus on a few of the scientific studies that were discussed in recent medical journals.

Personalized Genomic Medicine

In a recent blog I wrote about some of the controversies in the use of personalized genomic medicine.  In this week’s New England Journal of Medicine, there are two articles and an editorial about the selection of the right chemotherapy based on the presences of a gene.  The studies and the editorial point out that, at least in cancer treatment, the promise of using a person’s genetic makeup is a powerful way of guiding the best therapy.  Whatever controversy does exist about other uses, and potential misuses of genetic testing and analysis, it is clear that research such as this is guiding the way for using personal genomics in medical care.

Chronic Lyme Disease

There are certain diseases in our society that gain popularity as they seem to explain the problems of people with vague symptoms that no other diagnosis seems to explain.  Since Lyme disease is a multisystem inflammatory disease that can potentially cause many symptoms, there are those who believe they have this disease when they have diffuse aches and pains and fatigue.  In a study in the American Journal of Medicine, the researchers recruited 240 patients from an area that is endemic for Lyme disease.  Each of these people believed or were told by local doctors that they had chronic Lyme disease.  Less than 20% of these people had any evidence of any sort of Lyme disease either in the present or past (and standard medicine does not recognize chronic Lyme disease as a disease) however most did have a different medical illness or what is now called Chronic Multisystem Disease (meaning they hurt all over and we don’t know why).  Depression and anxiety were very common as were other personality defects.  The authors summarize by saying “multidisciplinary treatment addressing the physical and often emotional suffering of such patients will be more effective than perpetuating the diagnosis of “chronic Lyme disease”.  In my words, we often overemphasize a diagnosis when appropriate care in the absence of a firm diagnosis is really indicated.

Retail Clinics and Cost and Quality of Care

In the Sept 1 issue of the Annals of Internal Medicine, a study was described that looked at the quality and cost of care in retail clinics of the type found in pharmacies for three simple illnesses, pharyngitis (a sore throat), urinary track infection and otitis media (ear ache), compared to the cost and quality in physician offices, urgent care centers and emergency rooms.  Overall the cost of care was 30-40% lower in the retail clinics than in urgent care centers and physician offices and 80% lower than in emergency rooms.  The quality was care in the retail clinics was just as good as in the other settings.  The lower costs were due to lower unit costs since the retail clinics are usually staffed by nurse clinicians rather than doctors, and due to less lab tests being done.  Before we get too enthusiastic about this, this was a study of the costs for a comparable visits, not a study of total costs from the illnesses.  Since most sore throats just get better on their own as do some ear aches, the question is whether people who would have stayed home and just waited to get better went to a retail clinic instead, raising the total number of people being served and thus raising the total costs.  That is not known from this study.  But it does show that these retail clinics fulfill their promise of lower costs and high quality.

Modern Medical Myths

Medicine can be magical, filled with articles of faith and hope rather than science and rationality.  There are those who believe that this aspect of medicine left when the day of the witch doctor and the shaman was overtaken by the wisdom of science and the white coats that represent the modern health professional.  I submit that we still hold on to myths, even within the erudite discussions taking place in the press and in the public square as we debate health care reform.  Our myths have changed but they are no less powerful than the ideas that led to the bleeding of evil humors in order to cure disease. Let’s review some:

Most Illnesses are Preventable and Focus on Prevention will Save Money

It is true that many diseases are affected by our life style choices.  We eat too much, exercise too little and drink too much alcohol.  That all leads to disease which could be avoided if we all practiced moderation.  The myth is created by the idea that focus can greatly impact risk reduction to the extent that billions of dollars will be saved and the suggestion that people can modify their lifestyles successfully and prevent disease on a national scale.   The facts differ somewhat from this dogma.  Dee Edington and his team at the University of Michigan have been doing research in this area for more than thirty years.  In a recent, 2009 article in the Journal of Occupational and Environmental Medicine they looked at a large population that they had followed for eight years, assessing them yearly through questionnaires (health risk assessments) and providing multi-dimensional health risk reduction programs.  Their findings were that any positive change in reducing risks was minimal.  In that April 2009 article they stated: “No argument exists against the relationship between higher risk and higher health care cost, but optimal strategies for facilitating and sustaining changes are still elusive.”  Dr. Edington has told me personally many times that the real goal of health risk reduction should be to try and keep people from increasing their risks rather than try and get the true reversal of risks as that true reversal has thus far not been possible for large groups of people. 

All Diseases That Are Discovered Early Can Be Treated To Cure

If this were only true!  We know that early detection of hypertension allows for treatment and can help prevent certain types of heart disease and that early detection of some cancers allows a better likelihood of cure but the needed research has to be done on a disease by disease basis and may not hold true.  Prostate cancer, and the use of a Prostate Specific Antigen (PSA) blood test to try and screen for that cancer are an example of screening that may not help people survive.  In the words of the  American Urological Association Best Practice Committee on PSA, “at this point it is not possible to state that screening is associated with more benefit than harm”.  Every positive screening test for any cancer will cause more tests and procedures to be performed.  All of these diagnostics carry their own risk and we often do not know if that one case found may be causing more than one person to end up with a life threatening complication of an unnecessary procedure.  Even when we do find a cancer early, there is no guarantee that we can effectively treat it at that point.

The Ultimate Myth: Death is Optional

There is an old saying that life is a fatal disease.  In our society we often don’t act that way. We tend to want to find answers that tell us that death and illness are always avoidable.  That is not the case.  We fight disease and we prolong life and we try to do it in a way that celebrates the triumph of life and that never loses hope. We can do that without fooling ourselves with myths.

Myths and Health Reform

All of this comes to mind as we discuss massive reform in our health insurance systems.  My advice is to be skeptical of claims that we will save money by decreasing health risks in the population.  Question the dogma that earlier detection of disease will inevitably lead to more cures at lower costs.  Medicine is much more complicated than that and health reform is still just a piece of legislation and will not change human physiology and human behavior. 

The New Fortune Tellers

I can predict the future!  I can tell you your past!  So read the ads.  No, this is not a new Dan Brown novel or a late night infomercial.  It is the promise of those companies that advertise genetic testing for the masses. 

Personal Genetic Testing bypassing the Doctor

Direct to Consumer (or DTC as it is referred to in the medical journals) advertising of medical and quasi medical genetic tests is now widespread and becoming popular.  A person who so desires can send a cheek swab to a laboratory to have their genetic profile analyzed for a whole host of reasons.  What disease are you at risk for?  Who were your ancestors?  What can you do to forestall disease?  This is becoming so popular that the National Institute of Health in conjunction with the Center for Disease Control convened a workshop to discuss the use of personal genomic services and then published in the August issue of Genetics in Medicine a series of commentaries based on the workshop

Validity and Usefulness of the Tests

There are real questions about this testing.  As the first article in the journal states, “Some scientist have voiced concerns regarding the scientific foundation for the clinical validity(CV) and the clinical utility (CU) of PG (personal genomic) tests and the potential impact on our health care system.”  The fact is that for some tests, such as the genetic tests for breast cancer risk, we know that they have a place in the prevention and treatment of disease however for the great majority of these tests, we just do not yet know whether the association of the specific gene or genes with the disease is truly causative and therefore valid and even if valid, if knowing is going to assist in prevention or treatment. 

The Potential Culture War

In one of the commentaries, James Evans and Robert Green discuss the animosity between the scientific community and the DTC companies now selling the services.  They make a distinction between the companies’ science and quality of testing and the messages they then deliver.  “We may disagree with their choice, interpretations or presentations but they have already been transparent enough about their methods that they cannot be considered fraudulent.”  The better companies in the DTC business uphold scientific rigor in testing however they tend to minimize any possibility that medical information used inappropriately or prematurely can lead to real harm, either directly or by leading to medical interventions which carry risk. 

A Trend to Personal Knowledge and Responsibility

I tend to welcome any trend that puts people in charge of their own health decisions however I do worry about testing that is “hyped” and sold rather than arrived at with reason and thought. Personal genomic testing will change medicine and I only hope it will change it in such a way as to improve care while also putting the person at the center of all health care decision making.

Finding the Care In Health Care

In the midst of the debates over health reform, it is sometimes hard to remember that medicine is practiced on a very individual basis between one patient and one health professional (doctor, nurse, pharmacist) interacting in a very human manner. The Journal of the American Medical Association does publish a column called "A Piece of My Mind" and many of these pieces are by physicians who remember that imperative to care for the patient and not just diagnose and treat the disease.

"The Other Person"

This week, Dr. Paul Rousseau reveals himself, in writing "The Other Person" to be the caring physician we all wish we could have. In that "Piece of My Mind" article from this week's JAMA, he describes his meeting with a family to discuss the way to support the matriarch of the family, now 83 and infirm following a stroke, through the end of life. Read this and you find a discussion much more about life than about death. Much more about triumph of the person rather than pain control and advance directives. You read about a physician caring for a family and for the patient by understanding their lives, not only their deaths and not only their diseases.

Medicine, Productivity and Lowered Costs

When I read this piece, one thought jumped out at me. This session with the family is very unproductive. It probabaly took too long as talking with someone and just letting them talk about their past, takes a long time. A doctor with fifteen minutes per patient would be deemed an unproductive one by most business and management measures delving into items as irrelevant as the husband's background developing the GPS system for the military and the wive's background as a homemaker and librarian. Well at least under the advanced care planning reimbursement in the HR3200 bill the physician would be paid for that. Well maybe.

Advanced Care Planning Requirements

If we review the 1,493 words in that section of the proposed HR3200, we see specific requirements that must be fulfilled to be paid. Did Dr. Rousseau be sure and fulfill the requirement of providing "The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965)"? I did not notice it in the article but he may have. Would, under a new law, Dr. Rousseau be required to have someone sign a form certifying that all had been done (that was mandated under law) in the counseling session to allow him to be reimbursed for that service?

Caring as a Goal

I don't know how to fulfill the goal of allowing all to have caring physicians in their hours of need but I do believe that it takes more than legislation. In the words of Dr. Rousseau, "It seems that we physicians have strayed from the biopsychosocial model of patient care as well as the humane and personal touch that is so essential to healing and instead have chosen to hide in clinical foxholes where CT scans, laboratory data, and mundane and tangential information is discussed, far far from the bedside, and far far from the essence of the patient. " As we debate how to reform health care, lets think about how to reinforce the ability to find and treat the essence of the patient and not just the disease that they have.

That CT Scan Is Harmless so I Might as Well Have It?

That statement that introduces this post is one I have often heard from patients and even doctors to justify doing a test that is likely to yield very little useful information. An article in this week's New England Journal of Medicine actually spells out the real risk of diagnositc imaging exams.

The Cumulative Effect of Radiation

Radiation effects on the body are cumulative. That is why we require health professionals who deal with this modality regularly to monitor their radiation exposure. More than 100 mSv in a five year period, or more than 50 mSv in a single year is considered dangerous. This article looked at records of almost 1 million people and found that, just from diagnostic studies, more than 4 million Americans each year have diagnostic radiology exams exceeding 20mSv per year, putting them on a path to having more than 100 mSv in five years if that dose is continued.

The Worst Offenders

Myocardial Perfusion Studies are the greatest contributors to these high radiation doses that create risk for patients. Abdominal Pelvic and Chest CTs also are major culprits and many of these exams are routinely encouraged "just to be safe" when the safest course may be to avoid these tests.

Understanding the Danger

The accompanying Perspective in the New England Journal points out that most doctors do not know of this danger. Only 9% of ER doctos knew that CT scans delivered high radiation doses that could be dangerous. It is estimated that diagnostic studies may cause 2% of all cancers each year. People should know that these tests aren't harmless and should only be done if they are likely to give results that will impact treament.

Ethics and Reform

Dr. Emanuel as Lighning Rod

In any political debate, each opposing camp always attempts to find and keep the moral high ground. In our current national discussion about health reform, Dr. Ezekial Emanuel has become a "lightning rod" in the words of an article published in the New York Times today. I have read a number of Dr. Emanuel's papers through the years , even writing about one of his articles in a recent posting that I made in this blog. Dr. Emanuel has communicated thoughtful and nuanced analyses on numerous difficult ethical topics and must be considered to be one of the best thinkers in bioethics today. I agree with the New York Times article that laments "how subtle philosophical arguments that have long bedeviled bioethicists are being condensed, oversimplified and distorted in the griddle-hot health care debate".

Challenges in Ethical Health Law and Regulations

However, the ethical considerations must be evaluated in any law that is proposed. The real challenge is that nuance in academic discourse must be translated into legislative language that is ultimately then translated into very specific regulatory language to enforce the new law. Shades of grey and individual judgments that are customized by the specifics of each person and each situation often fall prey to the black and white of staying strictly within the law and the regulations. The flexibilty that is often critical in interpreting ethics within the individual's situation may be easily lost to forms, protocol and "fairness" that may be ultimately unfair.

The Example of HIPAA

One need only see how the ethical goals of maintaining proper privacy and confidentialty has been lost in a sea of forms to sign and policies for health providers to follow with the implementation of the Health Insurance Portability and Accountability Act of 1996. Has the HIPAA law actually put a shroud around the teamwork that health care professionals have to use in order to best treat their patients by creating criminal penalties for intentional violations of privacy? Do patients really benefit from signing these forms? I don't know the answers however I do know that the HIPAA law is laudable in its intent but may fall short in its practice.

Health Reform Ethics

We need health reform. We also need to approach reform with pragmatism and care, understanding that strong goals and ethical thoughts alone, do not create good laws. To create good law there must be thoughtful attention to all the ways that the law will be implemented and the ethical outgrowth of those very concrete and tactical steps that follow the passage of any law. While the ethical underpinnings of the law may reflect pruity of purpose, the final result may be implemented without the ethics we anticipate.

The Need for Health Reform

Lest anyone misinterpret my previous blogs, I believe that our system is desperately in need of reform.  As I read President Obama’s opinion piece in the Sunday New York Times this weekend, I strongly agreed with some of the arguments he put forth to support health reform.  He highlighted a number of issues that are important to address in any health reform package and HR 3200 does effectively address those. 

Pre-existing Conditions Clauses

In that article, President Obama wrote “A 2007 national survey actually shows that insurance companies discriminated against more than 12 million Americans in the previous three years because they had a pre-existing illness or condition. The companies either refused to cover the person, refused to cover a specific illness or condition or charged a higher premium.”  While I would argue with the word “discriminate” as companies that do not discriminate and cover those with pre-existing conditions would have to charge higher premiums and would not be able to continue in business, the ability to exclude someone because of a pre-existing condition has been problematic for years.  If you speak to health insurance executives, they will tell you that they maintain those clauses in order to keep premiums low for select groups.  If you eliminate pre-existing conditions clauses, rates for many policies, especially individual and small group policies will go up.  Despite that I still believe that these clauses should be outlawed as they go against the basic premise of shared financial risk that is inherent in good insurance.  HR 3200, in Title I, Subtitle B, Section 111 does prohibit pre-existing condition exclusions and I see that as very positive. 

Policy Maximums

In that same article, President Obama states “They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or in a lifetime. And we will place a limit on how much you can be charged for out-of-pocket expenses. No one in America should go broke because they get sick.”  What he is referring to in this quote is the yearly and lifetime maximums that some policies have in place.  A policy may now state that over the entire lifetime of the policy, it will only pay to a maximum of 1 million or 2 million or 5 million dollars and after that the benefits stop.  Obviously, if you have a severely catastrophic illness and go over that cap, you have no recourse other than some sort of public program.  Here again, eliminating these maximums will increase premiums for everyone, especially those who have individual policies and policies through small businesses.  However I am in agreement that this is needed to prevent people from compounding their illness with severe financial distress.  Section 122 of the same section of the bill that I cite above states that insurance coverage “does not impose any annual or lifetime limit on the coverage of covered health care items and services”  I see that as a plus and a needed change in law. 

Pass Those Clauses Now

There is really no reason that our legislators cannot pass these two sections now as a separate law.  There is no rule that makes all of the pieces of this legislation fit together.  We can find agreement for individual parts of the bill and I only hope that we can find the political will to make those changes that are needed.