nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, July 31, 2010

Medical Cartoonville - 31 July 10

It's a boring day for interesting stuff on medical research.  I'm also having another allergic reaction to the blather about health care reform.

So....with more than a little sarcasm...


Informative Article In Consumer Reports On CAM

If you subscribe to Consumer Reports (not Consumer Digest), your September issue will have a cover story on dietary supplements and herbal products. 

If you don't subscribe, it's worth buying the issue at the newstand if you can find it.

My favorite part is the list of the most dangerous supplements:
1.  aconite
2. bitter orange (used for weight loss; risk for high BP, MI, stroke, arrhythmia)
3. chaparral  (used for arthritis, cancer, weight; causes kidney and liver damage)
4.  colloidal silver (used for infection; risk for kidney damage)
5.  coltsfoot
6.  country mallow (contains ephedrine; banned in the US)
7.  germanium
8.  greater celandine
9.  kava (used for anxiety; risk of liver damage)
10.  lobelia (used for airway problems; causes a tremor, reported deaths from OD)
11.  yohimbe (aphrodisiac; can cause high BP, arrhythmias, heart failure)

I've made notes where I know something about these items.  Some of them I have never run across.

But I've led a sheltered life.  I only use pharmacologically active compunds that have approved by the FDA for specific symptoms or conditions.  Even then, with caution.

Supplements are largely unregulated and these compounds get added in to various products that are offered commercially.  Unless you read the label and are familiar with the 10,000 different things that companies throw in, you don't really know what you're buying and what it's effects might be.

Other parts of the Consumer Reports story cover multivitamins and how to compare them.  The part of the story I have a problem with is the section on supplements that people could use.  They list glucosamine for joint disease, and there have been several recent well-controlled studies that have failed to show benefit  (see my post here for some of that data).  In addition it can alter glucose metabolism in animal studies.

They also put St. John's wort on their list.  I can't recall it right now, but I think there are problems here, too.

If you want to be safe, be skeptical.  Talk to your doctor.

Doc D

Friday, July 30, 2010

Another Blow To The Supplement Industry. Study: Calcium Supplements Harmful

This is for all of you who are eating crushed oyster shells every day.

According to BBC News (July 29), the study, in the British Medical Journal, said
"people who took supplements were 30% more likely to have a heart attack.  Data from 11 trials also suggested the medicines were not very effective at preventing bone fractures.  Almost 3m people in the UK are thought to have osteoporosis and many take calcium pills to prevent fractures.
In all 12,000 people aged over 40 took part in the trials of calcium supplements of 500mg or more a day.  The risk of heart attack was seen across men and women, was independent of age and the type of supplement given.  A small increased risk of death was seen in the study but was not statistically significant, the researchers said.  The reason for the increased risk of heart attack is not clear but it is thought the extra calcium circulating in the blood could lead to a hardening of the arteries."
Some doctors recommend calcium supplements for those who are risk for osteoporosis.  Others believe that a balanced diet and adequate Vitamin D from exposure to sunshine is all you need for prevention.  Note that the difference is the question or risk.  If you have a strong family history of osteoporosis, then calcium supplements and medications can be or the other or both.
But there are two reasons to be cautious about this research:
1.  Note that the risk of heart attack was increased but the risk of death was not statistically significant.  This means they need to go back and see why the first effect (MI) didn't impact the second (death).  In some cases, it could be a confounding factor in the experimental design, in others it could be that there actually is an increased risk of death, but it's covered up by the mass of other causes.
2.  Percent increases in anything need to be looked at closely.  For instance it some bad result occurs at a baseline rate of 3 in a million, and adding a new variable (like calcium) increased the rate to 4 in a million, that's a 33% increase.  But it's not particularly noteworthy.  (Note:  this is an extreme example, to make a point.  The data in the study was 111 MI's increasing to 143 with Ca)
In any case, common sense says to talk to your doctor.  There's a place for using calcium supplements; and a place for not using them.
Doc D

Chicken Producers Are Clucking About Additives To "Natural" Foods

So chicken injected with water is not "natural."  And?

According to the Assoc Press (July 30), the chicken industry is arguing about whether some companies can legitimately label their product natural if they inject water or broth into the meat to make it more tender and flavorful.  Of particular note is that the lobbying effort directed at the US Dept of Agriculture is funded by companies that don't inject anything, against their competitors who do.

This whole obsession with natural and organic foods is a tempest in a teapot.  I agree that we need to make sure manufacturers aren't injecting arsenic (which is found in nature, by the way) into our food.  And I think there is enough evidence to be concerned about animals raised with hormonal additives or injections; although the data is far from complete (most of these additives exert their effect, then disappear from the body, just like what happens when hormones are produced by our own bodies).

But to get excited about whether injecting water into chicken and labeling it "natural" is a Truth In Advertising issue....No.  And what about injecting chicken broth?  That's not natural either?  It's chicken, for heaven's sake.

Next thing you know, food companies will be arguing about whether chickens confined in a building can be labeled "natural."  Wait...we're already there:  the "free range" phenomenon (On second thought, the USDA has not regulated the term "free range" yet; obviously asleep at the wheel).

Millions will be spent lobbying the USDA for stricter definition of the terms "natural" and "organic."  And it has nothing to do with your health.  It's about taking more of your money, and businesses competing for it. 

I'm not going to get started on the bogus "natural and organic" foods fad.  I've ranted about that elsewhere.  Suffice to say that the benefits claimed are a classic example of the placebo effect.

Hemlock is a natural product.  It didn't do Socrates much good.

Doc D

Thursday, July 29, 2010

Medical Cartoonville - 29 July 10


Hormone therapy.

Doc D

Your Doctor Doesn't Know How To Treat Pain, So Lawmakers Have To Step In

In another move to tell doctors how to practice medicine, Washington State is developing regulations for how doctors prescribe pain medication.

Remember all the Hooey about "not coming between you and your doctor?"

The regulations are being considered for how patients with legitimate pain get treated; it's not about patients who are abusing drugs, or doctors who are acting criminally.

The state wants to tell you and your doctor when you are receiving too much medicine.  At some point the regulations would kick in and your doctor would have to refer you to a specialist who would review your pain management plan and either concur with it or change it.  As you might imagine, pain specialists are all for these rules, being the ones who would benefit from more referrals.

Doctors who fail to follow the rules will be subject to penalties and possible loss of license.

Pain is one of the most subjective symptoms.  Researchers have designed a number of ways to measure it, but nothing works better than the 1 to 10 scales you've seen displayed in clinics; 1 is minimal pain, 10 is maximal pain.  Patients are asked to give a number for where their pain is.  That's it.  There's nothing better to say whether someone is in more pain than another.

Doctors receive training in pain management in medical school that emphasizes multiple approaches--that narcotics have a place but should not be overused.  Practicing physicians are required by many states to undergo periodic training in pain management, which they must certify to the state medical board.

So, imagine this scenario.  You have a tooth extracted and develop an abscess.  The abscess is resistant to antibiotics and it's taking longer to improve than most dental complications.  In the meantime, the unremitting 24/7 pain is driving you nuts.  The only thing keeping you from shooting yourself is the narcotic pain relief.  At some point the regulations kick in, whether through some total number of pills, or days under treatment, or level of narcotic, that you must see a pain specialist in order to continue treatment.

In my area, the wait to see a pain specialist is 3-4 months.  How helpful is that?

If doctors are not following best clinical standards for something as basic as pain management, then the answer is education, not regulation.  This is another example of legislating medical practice.  Recall my post on one state's new law about the long-term treatment of Lyme Disease.  Also, recall my description of the President's Town Hall where a patient expressed his frustration with not being able to get the only effective medicine for six months because it was too expensive, and the President's reply that "that's how the system should work." (it's a long post, see near the bottom).

I see this as a trend.  Interest groups and government agencies all want you to receive the care they deem appropriate...despite the fact that it's your health, not theirs.

Doc D

Wednesday, July 28, 2010

Surgery Residents: More Rested But Less Experienced

And the controversy over training hours for doctors goes on and on...

A study in the Archives of Surgery (June 2010), makes the case that limiting surgical residents to 50 hour work weeks has had a negative effect on training and quality of care in Sweden.

This is just the latest in a back and forth battle about how many hours residents who are in specialty training should work every week.

Although I went through training when there were no limitations on hours, and I often worked over 100 hours a week, I harbor no misgivings about that being necessary for effective training.  No macho "it makes you tough" assertions, or "If I did it, they should" nonsense. 

Yes, I was tired and had no personal life.  But in one year of general surgery training I did twice as many operations (under direct supervision) than I would have otherwise.  My training program was extreme, but I remember hearing that surgical residents who worked at the Mayo Clinic rarely were able to do any cases of their own in their first year of training, while I had done at least two hundred.

There's an argument to be made for having residents rested when they work.

There's also an argument that the more patients with different problems you see, the better doctor you are.  And unless you want to double the years it takes to specialize in general surgery from 5 to 10 years (any sub-specialization would be on top of that), to gain the exposure, then more time spent taking care of patients--in the time available--increases expertise.

A corollary to the "longer hours are better" argument is that frequently passing off your patients to other doctors, as occurs with limited hours, introduces error also.

For Onion Peelers,
Residents and consultants indicated a negative effect of the 50-hour workweek limitation on surgical training (62.8% and 77.2%, respectively) and on quality of patient care (43.0% and 70.1%, respectively) (P < .001 for both). Most residents and consultants reported that operative time (76.9% and 73.4%, respectively) and overall operating room experience (73.8% and 84.8%, respectively) were negatively affected by the work hour limitation. Only 8.1% of residents and 4.9% of consultants perceived the work hour limitation as beneficial to surgical training. Conversely, 58.4% of residents and 81.5% of consultants considered that residents' quality of life had improved (P < .001).

So what's the optimum?   I'm not sure.  I'm hard-pressed to say it's really just an issue for surgical training.  The more patients you see in any specialty, the better you get.  Is 60 hours enough?  80?  Or go back to the open-ended scheme that was traditional from early in the 20th century through my training era?

Recall that Dr. Kildare (1930's) LIVED in the hospital.

Doc D

Stem Cells Phone Home

Recent studies in the journal Nature suggest that stem cells produced from adult tissue may tend to revert to their cell of origin.

If true, it means the cells would be less useful for stem cell research.

The Washington Times reports (July 19) on the research, and the signal study is here in Nature (19July 2010).  Stem cells produced from adult tissue have some advantages:  there's a lot more of it around, you can convert them to partially differentiated cells of different types, and there's no need for embryo's to harvest the cells.  Unfortunately, in practice, they retain the genetic code to revert to the original tissue from which they came.
"Called "induced pluripotent stem cells" (or iPS), the altered adult cells "forget" they were once cells naturally "programmed" to become liver cells, lung cells, skin cells, etc. This would make them, theoretically, as useful as embryonic cells for a variety of miracle cures, especially for degenerative diseases such as Alzheimer's.

It turns out, the studies say, that they don't forget." (From Wash Times)
This study is observational, meaning the researchers haven't delved into why or how often this occurs, so these findings have to be considered preliminary.

The news report creates its headline from the speculation that this undermines the credibility of arguing that embryonic stem cells are not needed--that we can obtain just as much benefit from adult cells without engaging the moral repugnance some have for using embryo's.  This is a giant leap ahead of the science.

The news articled failed to report that the researchers also said that
"Such an ‘epigenetic memory’ of the donor tissue could be reset by differentiation and serial reprogramming, or by treatment of iPSCs with chromatin-modifying drugs."
In everyday English, you could treat those adult-origin cells to "reset" their stem cell capability.  This would restore their usefulness.

By contrast, while the researchers thought embryonic stem cells would be more stable, it's clear that stem cells from any source--adults or embryo's-- exist for the purpose of differentiating into specific tissue cells.

And embryonic cells are not immune to that process.

Bottom line, we need to wait and watch.  This research is still preliminary and it's too soon to be making claims about political and moral implications.

Doc D

Tuesday, July 27, 2010

Can Drugs Work On Patients In One Country But Not In Another?

The FDA will be considering approval of a new blood thinner (Brilinta).  The research suggests that it doesn't work as well on US patients.  Could that be true?

The Wall Street Journal lays the groundwork for this curious finding (July 27).  A review of the analysis submitted by the researchers to the FDA doesn't come up with a final answer, just some suggestions.
"In a review posted to the FDA’s website yesterday, the agency noted that the drug didn’t fare favorably against the market leader, Plavix, in North American studies. Across the entire population of patients studied, however, it reduced the incidence of heart attacks, strokes and deaths related to cardiovascular causes by 16% compared to the other drug."
The casual observer might speculate that humans in the US are different from humans in other countries.

But there are other (less dramatic) reasons that might explain this effect.  In the US we are more likely to use aggressive aspirin strategies to reduce risk of clotting.  We also use the cholesterol-lowering "statins" more often; some of the statins can reduce the effectiveness of blood thinners.

So there are reasons why the new drug might not work as well  here, based on outcomes driven by other treatments US patients receive.

The bigger question is, do you approve a drug--for use in this country--if it has a measurable impact only in other countries?

Probably yes, because individuals are not statistics, and some may benefit...if not enough to make the statistics significant.

And we are sure the new drug doesn't introduce new risks other blood thinners don't have.

Doc D

Ethics Of Posthumous Egg Donation

Interesting case in medical ethics.  When is it justifiable to take germ cells from individuals with terminal illness or injury, for the purpose of producing a child by that individual?

We're not talking about someone who learns of a fatal illness and has time to procreate in the usual way.  Not even those cases where a woman attempts to carry a pregnancy forward to childbirth before succumbing.  This is where the situation is more immediate.  No pregnancy can be underaken (by self or surrogate) in the time remaining.  In fact, in some cases, the individual may be on life support without the possibility of recovery, and the question is, do we allow cells to be harvested before removing life support.

It seems pretty straightforward that an individual who knows they are dying can make the decision to permit spermatozoa or oocytes to be collected and stored, if the partner wants to attempt to have children after the spouse has died.

But there are a couple of complications:
1.  What if the terminally ill person is not able to convey their wishes (coma) or made no verifiable statement about their wishes on a prior occasion?
2.  If what's needed are eggs from a dying woman, the process of stimulating the ovary to release oocytes would take about two weeks.  The process itself could be harmful to a comatose patient, hastening death.

The New England Journal of Medicine reports on just such a case (July 15).  A 36 year old woman collapsed in-flight, had a cardiac arrests, and was resuscitated.  After 11 days she was deeply comatose, with little brain activity.  Consultation was made with the family, and the breathing tube was removed.
"Several hours later, in the middle of the night, the family approached the on-call physician and asked that maximal medical therapy be resumed, to permit consideration of oocyte retrieval from the patient, for the purpose of posthumous conception of future offspring."
The question for the ethics committee was whether there was any evidence that she would have wanted this.  The husband admitted she was on birth control, but they had talked about having children later in life.  He also admitted that he had not wanted children prior to the mishap.  No testimony that was reliable and objective could be elicited from family or friends.  "We think she would have wished this, had she thought about it, but she never did"  is not good enough.

Secondly, the two week process to harvest an egg would be uncertain, and in any case, would required her to lie flat in bed which would worsen the brain swelling that had brought her to this vegetative state...and most likely kill her before the two weeks were over.

One final note:  preserving eggs and embryo's by freezing has improved in the last five years, but is still not extremely reliable.

In the end, all the doctors, ethicicsts, and lawyers couldn't make a case that it was in the interests of the victim that they accede to the family's request.  Terminal care was resumed until the patient died.

There are some other wrinkles here that will certainly come up in the future.  What if the patient had been male (no two-week period needed)?  What if the patient was female, and HAD given consent, but still the two-week period would have killed her?   Finally, consider all the political and social implications of other unique cases:  what if this was a same-sex couple?  What does the law say about that?  I don't know.

In any case, if you have specific desires for how you want things to occur should you be so afflicted, it's critical to think it through and get it down on paper...ahead of time.

...unpleasant as it may be to contemplate.

Doc D

Monday, July 26, 2010

Doctors Can't Get Federal Malpractice Coverage For Volunteer Work To The Underserved

A bill passed by the House (again) is stalled in the Senate by trial lawyer lobbyists.

For years, both the federal government and doctor groups have been asking to be included under the Federal Tort Claims Act for volunteer work in clinics that provide medical care to the underserved.  Once again, powerful interest groups have influenced Senators to sit on the bill.
"One factor is that a number of states have adopted laws limiting liability or capping awards for non-economic damages under the FTCA, making the expansion to CHC volunteers unpopular with a group hugely influential on Capitol Hill: trial lawyers.

“It’s just too difficult to move things that [the trial lawyers] don’t like,” Hobson said.
The American Trial Lawyers Association did not return a call requesting comment Friday." (The Hill, July 24)
I've considered joining or opening a free clinic in my area several times over the last few years--I have time available, and can do primary care--but I always come up against the cost.  I can't work for free, and pay $30,000 in malpractice insurance to do it.  I've even thought of just doing it without coverage, telling the patients that there will be no recourse to a large financial award, if they're unhappy with my performance.  If they can't accept that, then they should go somewhere else.  I've never been sued in 30 years, so this puts me in the minority, and I consider myself competent.

In Texas, they can't take your home or your car.  I don't have any other property, and not much in savings, so  that wouldn't be a big loss.  I don't know if my retirement pay would be affected if successfully sued.

In any case, I can't convince myself that it's a safe thing to do.

But, just in case you were in any doubt as to why tort reform, which has been accomplished in most other health care systems, can't get a leg up, this is more evidence that it's the trial lawyers.  Disgraceful.

Doc D


Long Ring Finger Means High Risk of Prostate CA?

Oh, and by the way, it also means you have LOWER risk of heart disease.

I love the media (OC Register, July 26).  They come out with the dopiest news stories.  This one reports on a study done to examine the length of men's ring finger and  and testosterone levels.
"The study, which examined 366 men over the age of 40 at a hospital in South Korea, claimed that male babies who are exposed to a high level of the hormone testosterone in the womb can grow up to have an elongated ring finger on their right hands. Testosterone is thought by some doctors to be an influential factor in prostate cancer, just as estrogen is suspected to affect breast-cancer incidence."
Wait, I thought they were talking about finger length and cancer...

The overreach in this story is classic.  Yes, there is some issue of testosterone and the incidence of prostate cancer, but it's controversial and not clear how it works.  It could be some third, or fourth, or fifth intermediate factor that influences both testosterone and cancer that could be behind all the correlation results.

Say this to yourself fifty times, "Correlation is not causation."

I've been staring at my ring fingers now for 5 minutes and can't convince myself that either one of them is longer or shorter than the index finger.  What does this mean?  And what does it mean if one ring finger is shorter and one is longer?  I assume some people can have that.  Do they get prostate cancer on only one side of the body?

See how ridiculous this all is?

OH, and the real howler comes when the BBC tosses in the French study that dogs can sniff out a molecule in the urine of men with prostate cancer.  Pretty cool, huh?  Apparently the dogs had "correctly identified 63 of 66 samples from cancer-stricken men. The dog had to pick the positive sample out of a set of five."

Before you go track down Fido with your urine sample, it's only Belgian Malinois shepherds that can do this.  Sorry.

But maybe it had nothing to do with smell.  Maybe the dogs were just thinking, "This guy looks like hell."

Hilarious.  Great wake-up for a Monday morning.

Doc D

Friday, July 23, 2010

A short video before I sign off til Monday.

If you look at "What I'm Reading" near the bottom of the Nostrums blog, you've noticed I list  One Nation Under Therapy, by Sommers and Satel.  It's funny and tragic at the same time.

The book explores how we have medicalized every event of our lives:  kids get sad that they don't win at the game of musical chairs?  Re-design the game so there are always enough chairs.  You are upset at having seen an auto accident?  You have PTSD.  

And the process of re-interpreting life's ups and downs into diagnosable conditions that require therapy goes on and on ...

In case you haven't seen it,  here's the antidote.  Many of you will recognize Lee Ermey from the movie Full Metal Jacket.


Doc D

Thursday, July 22, 2010

Nostrums Service Notice

Readers of Nostrums:

I will be unavailable for the next two days.  Sorry for the interruption in posting.

I'll be back on Monday.

Doc D
PS:  Looking back, there have been over 300 posts since the end of April.

More Good News From HCR: Limiting Choice Of Doctor

Backroom conversation:  "They bought it!  The fools.  They really think we'll let them keep their plan."

From the NY Times (July 17),
"As the Obama administration begins to enact the new national health care law, the country’s biggest insurers are promoting affordable plans with reduced premiums that require participants to use a narrower selection of doctors or hospitals.
 The tradeoff, they say, is that more Americans will be asked to pay higher prices for the privilege of choosing or keeping their own doctors if they are outside the new networks. That could come as a surprise to many who remember the repeated assurances from President Obama and other officials that consumers would retain a variety of health-care choices."
Actually, he said you can keep your plan.

I guess not.

[One caveat:  incentives to select from a network of physicians are not new, they're typical.  My plan does this.  But when you join those plans you know that.  They don't lie to you about it.]

Despite all the denials, the fact is that options will be limited, people will lose their plan and their doctor.  From a political perspective, it will be interesting to se all the excuses we'll hear (read the article for the first round). 

I expect some or all of the following (based on watching political damage control over the years):
--We didn't really say that.
--You misunderstood.
--I didn't calibrate my words correctly
--It's less expensive this way.

--Many people change doctors anyway.
--It's necessary for this great plan to work.
--Don't you care about the uninsured?
--It's really for the best.
--You'll like it when you get used to it.
--You knew we really didn't mean it.

Don't you get tired of people thinking you're stupid?

Doc D

Wednesday, July 21, 2010

Diagnosing Cancer: Often Not A Simple Yes Or No

If pathology specimens are impossible to diagnose, does that constitute an "error?"

The NY Times has an article (July 19) about misdiagnosis of breast cancer.  The patient described in the article underwent biopsy of a suspicious breast mass.  The pathologic diagnosis was an early stage of breast cancer.  She underwent surgery to remove the mass (note:  this was not a breast removal, only the main lump), radiation, and chemotherapy.  Only to find out that more extensive evaluation of the mass removed failed to identify the early cancer seen on the biopsy.
As it turns out, diagnosing the earliest stage of breast cancer can be surprisingly difficult, prone to both outright error and case-by-case disagreement over whether a cluster of cells is benign or malignant, according to an examination of breast cancer cases by The New York Times.

Advances in mammography and other imaging technology over the past 30 years have meant that pathologists must render opinions on ever smaller breast lesions, some the size of a few grains of salt. Discerning the difference between some benign lesions and early stage breast cancer is a particularly challenging area of pathology, according to medical records and interviews with doctors and patients.
It's really tragic that this patient had to go through all this, but which would you prefer?  Treated when no cancer, or not treated when there was cancer?  (assuming no cancer and no treatment was not an option...we have a breast lump here that competent authority judged to be early cancer initially.)

This makes it sound as though the new technology has brought us to this.  Actually, while the earlier you detect a cancer does make it harder to characterize when the tissue is examined at biopsy, the underlying problem is in the nature of cancer.

When control of cellular growth and division begins to deteriorate, the cells produced can vary along a spectrum of appearance that extends from normal to very chaotic.  Along the way the type of cell becomes less like cells from the original organ, a process that's called de-differentiation

In normal tissue it's not hard to look under the microscope and tell a pancreas cell from a brain cell, from a breast cell.  But as each of these types begin to turn cancerous, in the process of proliferating, they sometimes lose their distinguishing features.

You might guess that the more disorganized and de-differentiated a cell line becomes, the more likely it is to be an aggressive malignancy.  To some extent that's true, but not always.

Pathologists sometimes use dyes, stains, and radioactive markers to identify cell types in addition to appearance, but once again there is variability in response.

Given all the above, the diagnosis is sometimes not clear, or there may be misleading findings.

Several years ago I had a lesion on my arm excised by the dermatologist.  I found out a couple of months later that it had been looked at by my pathologists, sent to other pathologists for other opinions, and finally sent to the Armed Forces Institute of Pathology in DC (at the time, they were the international authority).  The process had taken all of the two months.  In the meantime I had no diagnosis.  I thought, "Wow, it must be bad."  Actually they were trying to decide whether some atypical features meant anything.  They eventually decided it didn't.   Lucky for me.  It healed up and no problems since.

Take a look at my previous post on cancer behavior, and the decision to treat or not, here, for further evidence of indeterminacy.

All cancer is not cancer, and if our knowledge was perfect, not all cancer would need to be treated.  For now we need to err--if error there be--on the side of safety.

Doc D

Dr Siegel On What You Should Expect From Your Doctor

I'm working on another project today, and it's eating up my day.  In the meantime, I ran across this post on the Fox News Health Blog (July 21).

Please go to the link to see his comments, but here is the list:
1. A patient knows how he or she is feeling. A patient should never tolerate a physician who is dismissive of symptoms, but expect your doctor to explore what is wrong and explain.

2. Bedside manner and personal connection are not nearly as important in a doctor-patient relationship as ability and good judgement on the part of your doctor.
3. Look for a doctor who “thinks outside the box” rather than one who sticks to his own notions of your problem no matter what your complaints are.
4. A good doctor is also a good referral source for doctors and specialists who have other areas of expertise. A top physician knows when a problem is outside his or her area of expertise and when to refer.
5. Your physician shouldn’t be defensive when it comes to dealing with a family member or friend who acts as your advocate. This person should be able to engage directly in discussion with your doctor when needed.
6. The worse you feel, the more your doctor should investigate and consider new ideas. Don’t accept a doctor who is dismissive or considers you as a collection of organs or symptoms rather than as a whole person.
7. Don’t let your physician intimidate you; look for one who encourages you to speak your mind and engages in an open exchange of information. Doctors are human beings, not gods, and they should be humble and solicitous, not arrogant or haughty.
Unresponsive and arrogant attitudes should go without saying.  We don't have to put up with that anywhere, especially in health care.

If I was putting out a list it would include a couple of different perspectives:
--Don't hesitate to get a second opinion.  Good doctors aren't bothered by it (it's what they do as a patient.)
--Don't leave the examination room with any confusion about what's going on and why.
--Good doctors aren't afraid to say "I don't know."  Not everything has a simple diagnosis.
Doc D

Tuesday, July 20, 2010

Initiative: Make Doctor's Notes Available To The Patient

An initiative to provide patients with their doctor's notes, has some benefits and some wrinkles.

The benefit for both the doctor and the patient would be to reinforce and refresh what happened in a clinical visit.  Patients are sometimes overwhelmed, or worried, or in pain, and may not remember all that was assessed or discussed. 

The Wall Street Journal (July 20) describes the project:
"A study currently under way, called the OpenNotes project, is looking at what happens when doctors' notes become available for a patient to read, usually on electronic medical records. In a report on the early stages of the study, published Tuesday in the Annals of Internal Medicine, researchers say that inviting patients to review the records can improve patient understanding of their health and get them to stick to their treatment regimens more closely."
On the other hand, the WSJ says, if you read your doctor's visit notes and saw the annotation "SOB" how would you interpret it?  Clearly, it mean "shortness of breath," right?

Here's an example of a clinical note I might write:

32yo WF w 4y hx PND, SOB, c/o incr bilat L ext edema. No sig PH. Meds:  HCTZ, Dig.  Ex: NAD, HEENT clear, lungs CTA, cor RR w/o M.  2+ pitting L>R.  Pulses 2+ U/L ext. No nodes.  Neuro no M/S deficit.  ROM full.  R/O vascular, CHF, renal, metabolic.  Plan:  Met Panel, CXT, CBC, EKG,  Re-eval when complete.

[Note this is shortened and slanted to make a point.  It's not a real patient, and not what I would do.]

Either I have to write all this out long-hand, which would take about three times as long, get it transcribed, or you're going to have to ask me what the heck I was talking about.

Just because you have access to it, doesn't mean you can benefit from it.  More has to happen.  Fortunately, there are medical record software products that can take this jargon and substitute the long form without input from the doctor.  Doctors just need to proofread it, to make sure the software guessed right.

Otherwise, you may find yourself to be the other kind of SOB.

Doc D

More Of The Same Poison Pill: MA Employers Dropping Health Insurance

As I've written before, the Massachusetts health care program is the prototype for ObamaCare.  As was alleged in the debate over HCR, employers are dropping their plans.

The Boston Globe (July 18) reports,
In Sandwich, business consultant Bill Fields said he has been hired by small businesses to enroll about 400 workers in state-subsidized care since April, because the company owners said they could no longer afford to provide coverage. Fields said that is by far the largest number he has handled in such a short time.
“They are giving up out of frustration,’’ Fields said of the employers. “Most of them are very compassionate but they simply can’t afford health insurance any more.’’
The state's response is, "Uh....we can't confirm that...we haven't looked at the data yet."

But it's a growing trend, the paper reports.

The nation's experience will be parallel.  It took MA four years to go downhill, so there will be some delay at the national level, although some businesses are already taking steps to prepare.

Runaway costs are at the root of the problem.  Finger-pointing for political purposes doesn't help the problem  ("It's the insurers." "No, it's the hospitals."  No, it's the drug companies.")

Actually it's the system they set up. ("You can keep your plan...")

Doc D

Monday, July 19, 2010

UPDATE: Medical Quote Of The Day To Be Retired

I'm running out of interesting medical quotations.  Give me a bit to think of something new in the aphorism/maxim line.  Any suggestions welcome.

For now, I'll leave you with this piece of advice.
"You want to have a mid-life crisis? Fine. Ditch the firm, head off to Maui, shack up with a supermodel, but you don’t get to keep the Porsche."
--John Crichton (character in Farscape)

Britain's Health Service Overhaul: Looking At Health Rather Than Programs

I wrote recently on Britain's plan to overhaul their dysfunctional health care system by putting control back in the hands of doctors and patients.

Further indications are that they want to get away from process measurements, like waiting times, and start looking at their dismal results on patient outcomes (see my post on problems they see with their current system).  Like...did the patient get well?

According to BBC News Health (July 1),
The first set of new standards is to be developed by April 2011. Under the planned shake up of the health service the new NHS commissioning board would use them to hold GP groups to account. Family doctors are due to take over NHS budgets for their local community by 2013.
The Health Secretary Andrew Lansley said: "I want to free doctors and nurses to focus on what really matters - better results for their patients - instead of them being stifled by top down targets."

Access to care is always important, but when you lose track of how well the patients are actually doing, you've missed the point.  Britain's belated recognition that health care is about what happens with patient's health should be applauded.

But since we're marching down the same road they've decided to abandon, shouldn't we pay more attention to how poorly that worked?

Doc D

Sunday, July 18, 2010

Medicaid Patients Have Higher Surgical Mortality Than The Uninsured?

I'm not sure what to make of this study yet.

A paper was presented at the annual meeting of the American Surgical Association in April of this year that looked at surgical mortality by insurance coverage.  It hasn't been published yet that I'm aware of.

In other words, how many people died after operations based on what type of health coverage they had?  The options were Medicare, Medicaid, uninsured, private insurance.

It was a big study (893,000 cases), some 40K were Medicaid.  It was a common database (the Nationwide Inpatient Sample).  And there were significant differences.

You might expect that the uninsured would do worse.  That's why we did HCR, right?  To cover the uninsured, who were suffering from lack of access to care and prevention?

The study adjusted for age, gender, economic status, geography, and other co-existent diseases...all the common things you eliminate. 

Actually, Medicaid did the worst.  Here's the data provided in the abstract:

Outcome     Medicaid              Uninsured            Medicare              Private Ins
In-Hospital  1.97 (1.84-2.10)    1.74 (1.60-1.90)    1.54 (1.48-1.61)    Ref (i.e., 1.0)

[* p<0.001.  The numbers are odds ratios, with confidence intervals in parenthesis.]

The table says that if you are on Medicaid your odds of dying are 1.97 times that of private insurance.

BUT, it also says your odds of dying are higher than NO insurance:  1.97 versus 1.74.  That is unexpected.

Bloggers on the Right and Left will try to explain the data in the interest of their own ideology, but I'm not convinced that this is telling us something useful yet.  I want to see the article.

There could be differences that point to Medicaid being a poor setup to get people good medical care, or it could say that Medicaid patients don't get preventive care that others do:  either because they are not prone to, or because it's not as easy for them to obtain it.   But you would think the uninsured would have an even worse problem in these areas.  So, Is it behavior or systemic?  The data doesn't tell us either way. 

I recommend we forget the bloggers (except me, of course) and wait for more info.

Doc D

Mosquito-Borne Dengue Returns To The US. Why Not Malaria?

Do epidemic infectious diseases ever go away forever?

I saw a note in the USA Today health blog (July 17): about 40 people over the last year and a half have been diagnosed with dengue in Florida—confined to Key West. A survey of the population showed that almost 5% had been exposed over that period.

This is interesting because dengue has been unreported in the US for the last half-century. Yes, there have been scattered cases along the Texas-Mexico border when there were outbreaks in northern Mexico. But it was temporary and not an indication that the virus was returning to the United States. Most people have never heard of dengue though it’s the most common mosquito-borne illness in the world.

The cases from Florida, indicate that the virus is back in the in the continental United States…to stay, for now. Dengue is a febrile illness caused by a virus and transmitted by mosquitoes. No cure, no vaccine. The species of mosquito responsible for transmitting the disease tends to dwell in houses and can bite both in the daytime and at night.

Back when I was in graduate school in parasitology in the 70’s, I recall learning that the mosquito vector of malaria had been reported on the South side of Houston but not in the northern half, implying that the city was the northernmost area where the mosquito could be found. However there had been no cases of malaria in that area, and it was not considered a threat. Why was there no malaria? The opportunity for transmission was there. There was standing water; we all got bitten all the time…but no disease. Unknown.

So dengue is back, and other mosquito borne illnesses are still around. Annual outbreaks of West Nile virus appear to be waning. There are several vector borne infectious diseases that are present at low levels (St Louis encephalitis), but they tend to be rare, and occur in cycles.  Yellow fever hasn't been seen for a long time.

It just goes to show that you can't become too complacent about the spread of infectious disease. Is it possible that malaria could return to the US?  Well, it’s theoretically possible. We no longer spray for malaria like we did when I was a kid. The trucks would come down the street of our neighborhood, spraying what I assume was DDT, and for fun we would run through the fog of the spray. I’ve often wondered whether that exposure imposed any risk. Apparently not…so far.

That method of prevention wouldn’t meet current standards for safety. The threat of malaria and other mosquito-borne diseases is so remote, spraying was only partially effective, and the implications of breathing insecticide have not been fully studied. We were taught as kids to not allow standing water outside: we would empty rainwater out of barrels and old tires.

Again, could malaria, yellow fever, and dengue return in a big way? It’s possible. All it takes is (1) weather that mosquitoes like, (2) the introduction of the virus, (3) enough people around and available for mosquitoes to bite (so the mosquito can get the virus by biting an infected person and then bite someone uninfected) (4) standing water for the breeding of the mosquitoes, and (5) lack of awareness to detect and adopt preventive measures for the disease.

The last of these worries me a little. The detection and identification of H1N1 took several months.

And, I’m not thinking malaria when someone comes in with a fever.

On the whole, though, there are more important risks. You can’t prepare for everything.

Doc D

Saturday, July 17, 2010

Advocacy Group Gets Law Passed On How Doctors Should Treat Lyme Disease

What are the implications of allowing non-medically trained groups to pass laws facilitating a particular treatment regimen?

Should the American Diabetes Association push legislation that tells doctors to treat only with certain medicines and in certain dosages?

Apparently one group has been successful in doing something similar.  The condition:  Lyme disease.  The treatment regimen:  allow treatment with antibiotics for more than 30 days.  90% of cases are cured, if caught early, by short-term treatment.  According to the Cape Cod Times (July 17),
"A new state law that spells out the rights of physicians to treat chronic Lyme disease patients with long-term antibiotics is being heralded as a victory by advocates of people afflicted by the tick-borne illness.  The law is meant to prevent doctors who treat patients with antibiotics beyond the 30 days recommended by some professionals from billing insurance, (sic?) said Brenda Boleyn, who chairs the Cape and Islands Lyme Disease Task Force, a community organization comprised of local government, agencies and Lyme disease patients."
Is this a trend, legislature defining how certain conditions can or should be treated?  The HCR law has standards for preventive services to be offered and when, but makes no claim to decide how doctors should treat any particular disease (some fear the IMAP will do that).

There are several problemsOne, the benefit of long-term treatment of Lyme disease with antibiotics has never been established.   Most of the success stories are just that, stories.  Two, the studies done so far have failed to clearly distinguish between what naturally happens with Lyme disease over the long period and whether long-term antibiotics have anything to do with the course of the disease. 

Anecdotes such as the following:
"Nancy Wood of West Barnstable had Lyme disease that went undetected for six to seven years. She required three to four years of oral antibiotics to get better..."I'm doing great. I have my life back," she said. "So do a lot of other people" who have been treated aggressively, said Wood."

are just that...anecdotes.  And the plural of anecdote is not data.  It is equally possible that it took several years for her immune system to adapt to the consequences of her previous infection...and the antibiotics did nothing.  There's no way to know.

Three, advocacy groups such as the Cape Disease Task Force rely too heavily on testimonials (always suspect) and fail to understand how the science of medicine operates.  Their view is if it's even possible that this type of treatment worked for one person, then it should be approved.  They fail to consider the other side of the story.

Long-term antibiotic therapy is rarely justified because significant new harmful adverse reactions (in addition to those of just using an antibiotic at all) arise with extended use...rarely, they cause fatalities.

This is why the scientific community has been reluctant to endorse proposals for long-term therapy in Lyme Disease.  Some infectious disease specialists have used it, other says it's unproven.  But, there is a clear down side, and a not-clear upside.  It's quite possible that this form of therapy does more harm than good, or does no good, at this point.  Lyme disease is poorly understood, very difficult to diagnose, and treatment is often disappointing.

It may turn out that in selected cases, long-term antibiotics are the treatment of choice.  The science and safety aren't there yet.

But it doesn't justify a legal standard that advocacy groups should be making scientific decisions.

Doc D

Gov't: You're Right There IS Enough Money In Medicare Fraud To Fund The Uninsured...Told Ya.

Finally, some action on Medicare fraud, an $80B loss each year.

The feds apparently did something to crack down on Medicare fraud in the US, according to the Assoc Press (July 16):
"In all, 94 people - including several doctors and nurses - were charged Friday in scams totaling $251 million. Federal authorities, while touting the operation, cautioned the cases represent only a fraction of the estimated $60 billion to $90 billion in Medicare fraud absorbed by taxpayers each year."
You've heard the stories.  A pizza parlor in Florida that was filing claims as a blood transfusion clinic.  The dentist in NY who was filing claims for having done 4000 procedures in one day.

I made the claim a long time ago, before the HCR law was passed, that if we just could prevent or recoup half of what we lose in fraud to Medicare alone it would be enough to fund health care for every uninsured person in the country.

What's ironic is the Administration now agrees, but diverted attention from efficiencies that could be obtained from the system while they were trying to pass the massive overhaul.  Sibelius, the Secretary of HHS, now claims that it was the new law that gave them "new ways to go after folks that we've never had before."

This is false.  The ability to investigate and prosecute fraud was always there, just not done.  The resources available to enforce the law were not provided.  The data shows that Medicare only had enough people and money to investigate 1% of the fraud.

Supporters of the current HCR law were criticized for not doing what could be done simply and quickly.  It's too soon to know whether this new-found commitment to fight crime will be sustained.  As with many government actions, the emphasis may be on making a splash (to answer the critics), then over time letting the effort languish because they want to spend money on other things.

We'll see.  But it's nice to see that there's a little honesty now.

Doc D

Friday, July 16, 2010

Medical Quote Of The Day - 16 July 10

"Our profession, after all, deals partly with guess work; we do not deal in absolutes."

-- Paul Beeson, M.D. [1910 - 2007]


Approving New Drugs: Balancing Risk And Benefit -- Avandia V. Qnexa

The diabetes drug Avandia stays on the market, the anti-obesity pill Qnexa doesn't make the cut.

The FDA issued a second closely-watched decision planned for this week.  After allowing Avandia to remain on the market, but with stronger warnings over its use (designed to limit the risk of heart disease caused by the drug...see my post here), the agency decided that the balance between risk of adverse reactions and obesity benefit didn't favor Qnexa.

Comparing the two decisions, I would say these were wise choices.  Both drugs can cause harm in some patients.  On the one hand, diabetes is caused by a breakdown of the body's ability to regulate itself.  On the other hand, obesity--which can have consequences that are just as far-reaching as diabetes--is a problem of "oral intake" in most cases....that is, our ability to regulate eating.  The regulatory problem in diabetes is something we cannot control, the regulatory problem in obesity is...well...difficult to control.  But the first problem is entirely physiologic, the second has behavioral components.

I've written before regarding my reservations over treating obesity with a drug.  Like the nicotine patch to help smokers quit, it doesn't work unless the commitment is there to change.

To my mind, this weakens the usefulness of drugs targeting obesity.  With that in mind we should weigh more heavily any adverse reactions they cause in deciding whether to approve them.

Even the recommendation for Avandia to retain FDA approval is subject to being revisited.  In several more years we will know whether the restrictions and increased warnings have solved the heart risk Avandia presents.  It may be that further research will lead to a different decision.

That's the way science works.

Doc D

Some Doctors Don't Report Other Doctors Who Are Impaired

I've had several experiences of handling impaired physicians.  This is just a selection.

[I wasn't going to write about this, but after the misrepresentation in the press, I felt compelled.  ]

Case 1:  Inappropriate touching.  I was called to conduct a credentials review.  Result:  revoked privileges and reported to the state medical board. License revoked. Law enforcement was handled separately.
Case 2:  Reckless disregard for patient safety.  Internist did a treadmill on an allegedly unstable patient.  Result:  privilieges restricted while investigation was done.  Facts didn't support the reckless disregard, and records of care showed appropriate management of risk.  Privileges restored.
Case 3:  Drunkenness while on call.  Came to hospital intoxicated.  Result:  Rehab, reported to state board.
Case 4:  Arrest for unlawful carrying of a firearm.  Result:  Review of patient cases showed clinical competence.  Physician voluntarily underwent psychiatric evaluation.  Insufficient criteria for a diagnosis.  Returned to patient care without incident.

In addition to these, there have been many instances of doing a focused review of the care a physician was rendering and many peer reviews of patient records.  In a number of cases, I've required a physician to justify their clinical management in writing.

Not a one of these was easy, and only some of them turned out to be real.  The system works when you make it work.

That a study in JAMA (July 14) finds that some doctors don't report incompetence or impairment is not a surprise.  The fear of retaliation is real, and the distaste for getting into a messy fight is also a factor.  Anonymous reporting is a joke; everybody knows you made the report.

Nonetheless, it's a disgraceful performance.  There's a special trust in medicine that goes above most professional ethics requirements: as patients, we are at our most vulnerable when sick or injured.

I recommend you do the following:  most state medical boards maintain a page where you can look up your doctor and find out whether there have been complaints, disciplinary actions, criminal history, license restrictions, etc.  In my state the website is here:  Texas Medical Board.  Click on the "Check your doctor" link and follow the instructions.  Lots of info.

I just checked myself, and I'm still clean (whew!).  They even have where I was a couple of months late paying for my license renewal 24 years ago  (So? I was deployed to Egypt...I blew it).

Doc D

Tired Of Hearing Americans Say How Horrible Our Healthcare Is? See What The UK Thinks of Theirs.

From Critical Condition blog (July 14).  Why Americans think the British healthcare system stinks (references for the claims are given at the link):

--NHS doctors routinely conceal from patients information about innovative new therapies that the NHS doesn’t pay for, so as to not “distress, upset or confuse” them.

--Terminally ill patients are incorrectly classified as “close to death” so as to allow the withdrawal of expensive life support.

--NHS expert guidelines on the management of high cholesterol are intentionally out of date, putting patients at serious risk, in order to save money.

--When the government approved an innovative new treatment for elderly blindness, the NHS initially decided to reimburse for the treatment only after patients were already blind in one eye -- using the logic that a person blind in one eye can still see, and is therefore not that badly off.

--While most NHS patients expect to wait five months for a hip operation or knee surgery, leaving them immobile and disabled in the meantime, the actual waiting times are even worse: 11 months for hips and 12 months for knees. (This compares to a wait of 3 to 4 weeks for such procedures in the United States.)

--One in four Britons with cancer is denied treatment with the latest drugs proven to extend life.

--Those who seek to pay for such drugs on their own are expelled from the NHS system, for making the government look bad, and are forced to pay for the entirety of their own care for the rest of their lives.

--Britons diagnosed with cancer or heart attacks are more likely to die, and more quickly, than those of most other developed nations. Britain’s survival rates for these diseases are “little better than [those] of former Communist countries.”

I've written about the criminally incompetent system in a number of posts.  Just search under "Britain."

Doc D

Thursday, July 15, 2010

Top Five Posts For The First Half Of July

The following articles got the most readers over the last two weeks.

--Doctors Get Sick, Too - My Appendicitis Story

--Back Pain: OTC, Or Placebo. Which Way To Turn?

--Kids Eat Carrots With Cartoon Stickers To Entice Them...Once.

--"Boutique" Medical Care? Charge Extra To Some So Others Can Be Seen Free?

--What "Patient-Centered" Health Care Means...And Doesn't

Yes, including the following, that's six posts.   But for some reason, a cartoon came in number two. 

--Medical Cartoonville - 7 July 10

Doc D

Medical Quote Of The Day - 15 July 10


"You must learn to talk clearly. The jargon of scientific terminology which rolls off your tongues is mental garbage."

--Martin H. Fischer, MD [1879 - 1962]

How Is Healthcare Spending Laundered?

The media talk about spending on healthcare in the US all the time.  Ever wonder who pays?

Source:  The Long-Term Budget Outlook from the CBO

A couple of things to note:
1.  Adding up Medicare, Medicaid, and Other Public (VA, DoD) spending accounts for almost 50% of total spending in the US.
2.  Private insurance accounts for 36% of the total
3.  Out of pocket spending is 13%.  If you have no insurance this means nothing; your out-of-pocket costs are 100%,  But on average, Americans contribute directly to somewhat over ten percent of the spending (not including premiums, whether paid by the employer or the individual.)

Once HCR takes effect, I wonder how high the government piece will go?  And since we fund the government piece of the pie through taxes, I wonder how much that adds to our overall bill?

Doc D

The Preventive Is The Political Under HCR

Back in the Sixties, radicals would say, "The personal IS the political," implying that every thought and act has political implications. 

Mostly it was a way to compel conformity to a particular political philosophy:  there is no personal life, you have to be on board politically in everything you do.

Now prevention in health care is the political.

The US Preventive Services Task Force is a volunteer body of public health and medical experts who winnow the data on disease and injury to decide criteria for preventive medicine:  at what age should colonoscopy be performed, when should vaccines be given, what are the risk factors that indicate a treadmill?

Their signature publication, The Guide to Clinical Preventive Services: Report of the United States Preventive Services Task Force, has been the authority on prevention in the US.  Not that there haven't been controversies over specific recommendations over the years.  The question of what age to begin mammography became a media firestorm just last year.  But in general, you could say that their recommendations represented the best of what we currently know in the science of public health.

That may be changing (Kaiser Hlth News & WaPo, July 15).
"Under the new health care overhaul law, insurers will be required to pay fully for services that get an "A" or "B" recommendation from the U.S. Preventive Services Task Force, ...[which] puts the group in the crosshairs of lobbyists and disease advocates eager to see their top priorities – including routine screening for Alzheimer’s disease, domestic violence, diabetes or HIV – become covered services."
As an example the American Diabetes Association lobbied successfully to include a requirement in the HCR law that "the task force include in its reviews of evidence the guidelines drafted by specialty groups, language intended to help preserve diabetes coverage."

Thus, this special interest group gets power over the Task Force's recommendations.  Where the science is not clear, the ADA will argue for coverage...and likely will get their way.

Statements by the Task Force that the science will come first, have already led lobbyists to engage directly with HHS, according the Washington Post, to get their special interest group desires covered.

Talk about a food fight.

And if many of these groups get their way, it's expected to raise everyone's insurance premiums.

Clearly the preventive is the political.

Doc D

The Medical Home: Integrated Care, Or Care By Committee?

The medical home has been pushed by reformers as a way to bring together patients care, increase efficiency, and reduce duplication and error.  So far, the evidence is mixed.

People get the wrong idea of the "medical home" concept.  The term doesn't imply that there's a place, a "home," where health care occurs.  Care is still delivered in the doctor's office.  The difference is in how that occurs.  Instead of encountering the health care system as a series of fragmented events, the medical home attempts to integrated everything from disease management, prevention, physical therapy, social services, and all the rest into one seamless team-based approach to a patient's total needs.   It's a virtual "home."

Say you break your leg.  The physician, physical therapist, home nurse, psychologist, and social worker meet as a team to design comprehensive care for your problem.  At the same time that your healing leg is being managed by the doctor, the physical therapist has a program to keep your limbs and joints strong, the home nurse has a plan to visit and make sure you're on track with medicines and activity.  The social worker arranges for assistance if you can't take care of yourself in the acute phases.  Combined with electronic records--which all team members access, update and monitor--the entire team is up-to-date on your status, tracking your progress, and intervening if problems arise.

Team approaches to health care have been around for decades in one form or another.  The rudiments have existed for over a century as doctors and nurses have done regular ward rounds.  What makes the medical home new is its attempt to provide comprehensive care and to leverage computer health record technology.

What sounds great in theory has some issues, though.  As with most new programs where people sat down and tried to engineer an optimal process, the practical hurdles and unintended consequences surfaced almost immediately.

One peripheral issue is electronic medical record systems.  Policy makers are currently experiencing a backlash against poorly designed systems.  Commercial products have been put in place that led to patient treatment errors, and in one blockbuster case, a multi-billion dollar government system is under heavy fire after five years of struggling to make it work right (The DoD's AHLTA).

But the electronic record piece of the medical home concept is peripheral.  The real issue is the patient.  How well do they engage in the process, to their benefit and cost effectiveness, and how do they perceive it?

There have been warning signs that patients may not value evidence-based medicine in their care ( a study in Health Affairs, 3 June).  While most studies show improved quality of care and reduced cost, not all do.  And finally, some patients feel displaced and disoriented, uncertain that the new approach is bettering their care.

As with any endeavor that provides services to real human beings, the danger is in focusing on the process of caring over the well-being of the persons under your care.  People who complain about the corporate dehumanization in medicine, see the medical homeas  another step toward transforming them into an object, a collection of data points undergoing optimization in a scheme of care, rather than an individual with unique needs, strengths and weaknesses.

As Dr. Pauline Chen writes in the NYT (July 15)
"Yes, they were getting into their doctors’ offices more quickly and were being followed more closely than ever before, but many patients reported feeling disoriented. Some felt displaced as they saw the old one-to-one doctor-patient interactions replaced with one-to-three or one-to-four relationships involving not only the doctor but also a whole host of other providers. As offices switched from paper-based to electronic medical records, other patients reacted to the distracted clinicians who seemed more focused on learning the new computer system than on listening to them. Satisfaction fell because, like my friend, few patients were cognizant of, much less involved in, the changes going on around them."
I was on active duty in the Air Force when we began using team approaches two decades ago.  It was difficult for patients to see how it made things better, and we were spending so much time in team meetings doing care plans that it ate into the time available to see patients.  It was difficult to sustain team momentum in the face of documentation required to keep the team up to speed.  Doctors would miss team planning due to emergencies, other team members would substitute in the absence of the regular team member, knowing little about the patients currently under continuity suffered.  Feedback from patients was that it felt like being treated by a committee.  Engagement by the patients and commitment from the staff waned regularly and had to be reinvigorated.  When I retired from the military 3 years ago, these were still challenges.

Looking at the newest version of integrated care, the medical home, and thinking back on more simple efforts I was involved in, I think we'll continue to see these challenges.  But rather than seeing them as temporary impediments, I think they are inherent in a system of care that applies "scientific" methods to policy and management.  Any good manager can make the statistics look good on access or quality:  we all know how to pursue a desired data point.  But as long as the model is focused on how well WE are doing in taking care of people, the tendency by doctors, nurses, and other team members will be to look at the process--and a statistical measure of success--instead of a unique judgment about how individuals are getting along.

Whether it's Management by Objectives or Six Sigma, management philosophies come and go with great regularity.  You can bet we'll see the same in health care management (remember Managed Care in the 90's?  a flop).  There will be a lot of enthusiasm for medical homes for a few years, then it, too, will fade to make way for the latest great idea. 

That will be the fate of every program to address the "how" of health care over the actual well-being of individual persons:  it will feel like a visit to the DMV.

Doc D

Wednesday, July 14, 2010

President Obama's AIDS/HIV Plan In Comparison

Just some perspective on the statistics, and public health initiatives.

AIDS is a horrific disease.  Our concern is magnified whenever a disease targets a specific group of people, or that affect us by shortening life.  Similarly we are horrified by potentially lethal diseases that target children.

So it's the right thing to do to make some diseases a target for out public health efforts. The Obama Administration has issued a new plan to attack the spread of AIDS.  Despite a commitment to increase medical research, the President's initiative doesn't substantively increased funds in this project.  Rather, it re-distributes funds to areas that may have greater impact on access to care and disease prevention.

As a part of that effort, the following statement was made but not referenced:
"There is a new HIV infection every 9 1/2 minutes in the U.S. But about one of every five people living with HIV doesn't know it."
The first part is accurate.  The second is based on an estimate by the CDC.  There are 56,000 new cases a year.  If you divide the number of minutes in a year by this number, you get one every 9.38 minutes.

With current treatment, the lifespan of sufferers with AIDS has been extended, to decades in many cases.  But it means a life of treatment, fatigue, side effects, hospitalizations, and complications.

In this way it's similar to diabetes:  With treatment diabetics live for long periods, but have shortened lives due to complications, unstable blood sugars, treatment side effects, and such.

There are 1.6 million new diabetics each year.  That's one every 20 seconds.  And about one in four don't know it.

Despite being 25 times more common, and having a greater percentage of undiagnosed cases, public health initiatives to control and treat diabetes have given modest results.  The Women's Breast Health initiative of the 90's also had limited success, but has receded from the public's interest.  AIDS, as a disease with behavioral components to its spread, will pose additional challenges to control.

I'm hopeful that the President's new initiative will improve care and reduce the incidence of HIV.  Whether it succeeds as well or better than efforts with other diseases will depend on how they go about it.

Doc D

Medical Quote Of The Day - 14 July 10

"The practical man is one who practices the mistakes of his forefathers.

--Martin H. Fischer, MD [1879 - 1962]

What Makes A Medicine Too Risky

The emphasis is on "too" risky.  Every single drug has some risk. But do you want to do without them?

The issue has been much discussed recently, based on the FDA's review this week of the diabetes drug Avandia.  The reports seem clear that the drug increases the risk of heart disease (in this case, heart attacks).  It's been around since 1999, when it was first approved.  A previous review by the FDA left it on the market, but with increased warnings.

Diabetics are at increased risk of heart disease, and the drug appears to be effective in controlling blood sugar.  Researchers had to tease out whether the drug itself was causing an increase in risk beyond that caused by diabetes alone.  That was done, and in at least one study (NEJM, June 14, 2007), combining the results of many individual studies, Avandia (or rosiglitazone, the chemical name) DID contribute to additional risk.  The additional risk is not large, but it's real (so we think now).

As with most drugs, getting at the "why" of that increased risk has proven elusive.  Almost every drug on the market has effects on the body that go beyond what they were designed to do.  Avandia raises the bad cholesterol somewhat (LDL, 18%), it lowers hemoglobin levels slightly, it may increase blood volume.  If you have someone who is susceptible to heart disease, any of these--or all--could precipitate a heart attack or heart failure.  We don't really have a way to predict accurately whether any given patient is susceptible or not (given that they don't already have a history of heart attacks or heart failure).

Are there alternatives to Avandia?  Yes, but there's some question--and difference of opinion--whether the primary alternative, Actos, has the same risk...and if it does, is the risk greater or less?  Unknown.  Finally, the history of oral agents for diabetes is littered with drugs that have come and gone for one reason or another...sometimes due to  adverse reactions.

All of this--risk, cause-and-effect, effectiveness, precautions, alternatives--creates a complex decision matrix.  Adding to the complication, it's hard to say how many diabetes are alive BECAUSE of Avandia.  It's unethical to do research that gives treatment (Avandia) to one group of diabetics, and nothing to another, to compare the benefit of that specific treatment.  Untreated diabetes is probably the riskiest situation of all.

In the article referenced above, the authors point out
"The FDA considers demonstration of a sustained reduction in blood glucose levels with an acceptable safety profile adequate for approval of antidiabetic agents. However, the ultimate value of antidiabetic therapy is the reduction of the complications of diabetes, not improvement in a laboratory measure of glycemic control. Although reductions in blood glucose levels have been shown to reliably reduce microvascular complications of diabetes, the effect on macrovascular complications has proved to be unpredictable....the use of blood glucose measurements as a surrogate end point in regulatory approval must be carefully reexamined." [emphasis mine]
Putting the question of Avandia aside for now, is it possible to take a step back from all this and develop guidelines about risk that help us make complex decisions?  Doing that would force us to look at the risks of drugs in general.  Would doing that clear the air on the issues that pull us in different directions?

Going back to the beginning of the article, how much risk are we willing to accept to achieve benefit.  I hope it's clear from the discussion so far, that it's not just a simple matter of "do no harm."  Hypothetically, if you need treatment, discarding a drug that harms one person while thousands of others would have benefited is clearly not optimal, for you or for everyone else.  When you can't predict who that one person harmed will be, do we just forget about them and press on with the "greatest good for the greatest number?"

For those of us who think decisions in life are never yes-no, black-or-white...going down this utilitarian road of "greatest good"  leads to madness.  Philosophers and moralists have been arguing about this since the dawn of time.  If you're willing to accept one harmed, how about ten?  If the one harmed is "great" harm, and the benefit to the thousand is "small?"  Blah, blah, blah....

Rather than join in thousands of years of  argument back and forth, try this:

If you followed the discussion above about Avandia, then you are fully capable of making a decision about whether you would want to take Avandia for your diabetes or not.  Discuss all the information, look at alternatives, see what we don't know for sure yet, etc.  You decide.  Not your doctor, not the FDA, not ObamaCare...although all of these can be sources of advice and information. You should have a doctor you trust, who can work with you to lay it all out.

And just like when you get in the car every day--and risk having an auto accident--you take responsibility for the decision you make  (Actually, driving is a lot riskier than Avandia).

Ultimately, then, what makes a medicine too risky is your assessment, as the owner of your body, that something isn't right for you.  You exercise the freedom to choose.  I've written about what's called "patient-directed healthcare" before.  We need the research, the FDA, your doctor and all those things, plus absolute transparency of information...but when it comes down to it, you should have ownership and direction of what you do and don't do for your health. 

By contrast, what's been called "patient-centered healthcare," a concept championed by the new director of Medicare--a recess appointment by the President--Dr. Donald Berwick, puts the patient at the center of a healthcare system that does a lot of the deciding for the patient, offering to provide what is in the patient's best interest.  All they ask (as de Tocqueville said) is that you not question the "best interest" they offer.  See my post linked above.

Critics of patient-directed care say that patients can't ever absorb fully, or understand completely, in order to decide.   What do you think?  You read the situation above on Avandia; was it too hard for you? that's the assumption of "patient-centered care," "comparative effectiveness," and all the other programs that sound supportive, but assume that you can't decide intelligently.  Someone else--experts--needs to step in and take over for your lack of aptitude.

I don't know what the FDA will decide about Avandia.  Some people may die using it.  But some people die every year from Tylenol.  Maybe they can come up with some precautions regarding patients with heart risk that removes some of those patients that might be harmed.  But nothing is going to eliminate risk entirely, no matter how good a medicine is.

As one senior physician told me, "If you want to avoid risk, dig a grave and get in it."

Doc D

Tuesday, July 13, 2010

Medical Quote Of The Day - 13 July 10

"The 'light diet' of the average hospital is the polite term for starvation."

--Martin H. Fischer, MD  [1879 - 1962]

Re-Admission To The Hospital May Be A Poor Health Quality Measure

When you judge the quality of a hospital, there are a number of indicators:  wound infection rates, mortality, C-section rates, and re-admission within 30 days.  But the last of these may not be bad.

If you get admitted to the hospital for heart failure, undergo treatment to treat the condition, get sent home improved, and on treatment...that's a pretty good deal.  Heart failure is something that is almost never "cured," unless you get a new one (heart, that is).  But treatment can extend life for years.

You're now at home, doing well at first, but for some reason your condition worsens and you need to be re-admitted to the hospital.

Medicare views "readmission for any reason after an index hospitalization for heart failure as a sign of poor quality of care."  Comparisons by government agencies such as this one from Medicare will be the foundation for judging the health care we receive in this country under HCR.

Medicare reasons anything that could go wrong in the first 30 days should have been foreseen or addressed in the first admission.

At first glance, that sounds reasonable.  BUT, a closer look at Medicare's database shows that  lower readmission rates (good) are associated with higher death rates (bad).

Perversely, Medicare's quality measure could reward hospitals for more patients dying of heart failure.  Take a look at the graph:

The y-axis is 30 day mortality rate.  The x-axis is the 30 day readmission rate.  Put simply, the choices here are "how many die" on the left and "how many go home for a while, but have to come back", on the right.  Note that the chance of dying is higher when the re-admission rate is lower.  [Sorry for the poor quality graph, it's so hot-off-the-press, the online version isn't up yet]

So which would you choose?  The hospital that has a higher death rate, or the one that has a higher re-admission rate?

Clearly one way to have a low re-admission rate--which Medicare thinks is an indicator of high quality care--is to have more patients die.  Then they don't come back.  Voila!

The authors of this letter to the editor of the New England Journal, July 15 ("Are All Readmissions Bad Readmissions?") diplomatically suggest that a "nuanced" interpretation of Medicare quality data is needed.

I suggest we stop implementing crappy assessments of medical care quality.  In my experience, health care quality is always complex and "nuanced."

Doc D

Ethics And Certainty: Medical Decisions For Those Unable To Decide For Themselves

Interesting case:  Are relatives able to act as the patient would have wished about terminating life support?

From the BBC News (July 13), a case where a young man becomes a paraplegic after a motorcycle accident.  Unable to move or speak, and on artificial ventilation, the family asserts that, from their knowledge of statements he has made, he wouldn't want to live like this.

Enter the neurologist, who uses the fact that the injured man can move his eyes to ascertain that he is indeed awake and alert, understands his situation, and that it's unlikely to change...and can answer questions.

And he definitely wants to continue to live.

As the father later recounts (from the article linked above):
"It's all hypothetical and you don't know until it happens to yourself. As a family and friends, if that person can't decide for themselves, sometimes you feel that you can decide for them. Because, in theory, you think you can never live in that situation, you sometimes put that judgement onto somebody else. At the end of the day, you probably have no right to do that.  But now Richard's in the situation where that's actually happened. It's real life - it's not pretend. He is in that situation. The will to live takes over."
One lesson from this is that what people say ("if that happens to me, pull the plug"), may not be what they really think when confronted with it.

The second lesson asks a question:  how do you that what somebody said a year ago (a month ago? a day ago?) is what they still believe?  People change their minds...often.

Current law gives the individual the right to decide about extraordinary efforts to sustain life.  When they are unable, the authority passes to the closest relative (or the courts)...presuming they will act in the individual's best interest.

But do they?  How do they really know what the individual "would have" wanted?  In the case above, the father, and the family, would have made the wrong decision.

Can the responsible authority (the family member) substitute their own assessment of what the decision "should" be?

Most of us would say that it's proper to go to extremes to determine the individual's desires asking.  Absent depression, or mental competence, that should be it.   Once all efforts to extract a competent decision from the patient have been exhausted, the legal guardian (closest family member, the court) should decide.

But as the case above shows, they can be wrong...there's no guarantee.

Food for thought, if you're ever part of end-of-life decision making for a relative.

Doc D


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