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Clinical Issues

When Celebrity and Science Collide

by Jen Jenkins

Celebrity influence can often be considerable, even when it comes to health and medicine. Although this influence can sometimes be for good, it can also be harmful. Doctors are fighting now more than ever to seize the spotlight from celebrities when it comes to medical issues, as their voices typically have far more reach than medical journals. Most recently, this New York Times article discusses the case of a documentary film being pulled from the Tribeca Film Festival. The film, Vaxxed: From Cover-Up to Catastrophe, was pulled by Tribeca in the wake of an uproar from doctors and experts. The concern revolved around the extreme publicity of the event and screening a film that featured research into the connection between vaccines and autism — research offered by a disgraced former doctor that has long since been debunked.

Anti-vaccination advocacy is an issue that has been promoted by many celebrities and politicians as of late. Arthur L. Caplan, head of the Division of Medical Ethics at New York University, believes celebrities have an out-of-proportion impact on the public’s understanding of vaccine risk but he also added, “I don’t want to overplay it; most people vaccinate. It’s not like hordes of people are listening to Jenny McCarthy and saying, ‘Forget the American Association of Pediatrics, I’m going with the former Playboy Bunny.’” However, with so many celebrities heavily promoting new drugs, exclaiming incessantly about health practices, or offering opinions on health recommendations for infants and children, it is important to ensure the public understands that although celebrity health advice may be well-meaning, it can still be dangerous. “It’s part of the general impact celebrities are having on health,” says Caplan. “It’s a constant battle to try to correct misperceptions.”

Limiting Opioids for Patients with Chronic Pain

By Jen Jenkins

Pain is one of the main reasons people go see their doctor. Although it was once overlooked or often dismissed, it is now a standard vital sign in a patient’s work-up. However, unlike other tests administered in a medical setting, pain is difficult to measure because among other factors, pain tolerance is highly individual. The United States has had a long and complex history with chronic pain management. In the 1990s, doctors were reproached for under-treating pain and were told that opioids, including OxyContin, could not only bring unmitigated relief to patients but do so in a safe way. Today, doctors are again being admonished but for a very different reason. Politicians and policy makers continue to publicly denounce what has been labeled as the “opioid crisis,” due in part to doctors over-prescribing medication, namely opioids.

A growing number of states are enacting measures to limit prescription opioids and the federal government has issued the first national guidelines to help reduce the use of these highly addictive medicines. Dr. Robert L. Wergin, chairman of the board of the American Academy of Family Physicians, said he doesn’t want to stop prescribing opioids altogether but that he can see why some doctors have gotten to that point. Dr. Wergin has taken professional and personal risks in prescribing opioids. Closely monitored by state and federal officials, he must go through an elaborate prescription checklist. He has also been threatened by addicts, desperate for pills. His patients now sign “pain management contracts” and must agree to random drug tests before receiving an opioid prescription. “You don’t want to become so jaded that you assume everyone in the E.R. is a drug-seeker,” Dr. Wergin said, but he has seen firsthand a growing number of overdoses and opioid-related deaths during his emergency room shifts.

Collectively, primary care physicians write the greatest volume of opioid prescriptions and these same doctors are now scrambling to find alternatives for their patients dealing with chronic pain. Prosecutors and medical review boards closely scrutinize physicians who prescribe controlled substances. Many medical associations now offer doctors training about chronic pain, urging the use of other remedies such as physical therapy, acupuncture, anti-inflammatories, antidepressants, or counseling before prescribing opioids. Unfortunately, alternatives are unrealistic for some patients for a variety of reasons: physical therapy may be too expensive; anti-inflammatories cannot be taken by those with a compromised liver.

Some state medical boards have recommended limiting the number of opioid doses per month while others have recommended limiting the strength of daily dose. Dr. Wergin is careful not to promise patients a prognosis of being “pain-free” and chooses instead to talk with them about setting realistic goals to manage their pain. Although opioids help to alleviate severe pain, they are highly addictive. The epidemic of overdoses and death is real and the responsibility of monitoring patients for potential abuse falls largely on prescribing doctors.

Take a moment to read the following New York Times article and learn more about Dr. Wergin and what he is doing for his patients.

Tying Prices to Performance

by Jen Jenkins

For years, the government and private insurers have been attempting to make an important change in the reimbursement model under which doctors and hospitals operate. The fee-for-service system that is currently in place pays doctors and hospitals based on the sheer volume of tests that they perform and treatments that they ultimately prescribe.

It is quite baffling that a system like this was ever put into place because it by no means incorporates any incentive for ensuring the quality of patient treatment or overall outcomes. In fact, this system has led to a disconcerting trend of unnecessary testing and expendable costs. A change in the current model would mean rewards based on quality and better outcomes, not volume.

A similar shift in the reimbursement model may soon be evident in the drug and device manufacturing industry. Currently, the price of a drug or medical device is unrelated to its actual performance or quality of outcome for a particular patient. This has long been an unraveling problem (similar to that of doctor performance standards) wherein expensive drugs are not performing in the real world nearly as well as expected.

This issue also includes medical devices not working as anticipated; for example, a cardiac device that requires surgery to insert. Today you pay the price no matter what, but imagine being refunded completely if a drug or device did not work as your doctor promised. It’s slightly unfathomable based on the model we currently adhere to, but highly probable for the future of drug and medical device manufacturers.

In theory, this novel change sounds not only appealing but necessary. In reality, however, it becomes a bit complicated. What metric should be selected to measure performance and how will that metric be universally agreed upon? This is a question posed by a senior adviser from Analysis Group, a company that does consulting work for drug and device makers. Like with many other innovative implementations and changes in today’s society, new technology may need to play a role in this shift. However, drug companies want to be sure that patients are taking medications correctly and consistently while also adhering to other factors, such as specific diet or lifestyle changes, that are put into place by doctors. These components all play a role in the effectiveness of a drug. In response to this problem, technology company Qualcomm Life is currently working on a combination of software and sensors to monitor patients, a necessary part of making this change possible.

All obstacles currently in the way of making these changes a reality are seemingly practical ones and thus solvable. It is very likely that sooner than later we will see an inevitable change in which drug and device makers are sharing the risk where the outcome of the patient’s health is concerned.

Some examples of discussions and possible reasons for following the new model are highlighted in this Bloomberg Businessweek article.

The Vaccine War

by Angela Sams

Many of us likely saw or at least heard about the picture that Mark Zuckerberg, co-founder of Facebook, posted on the social media site recently. Though perhaps it appeared innocent on the surface, the photo of his two-month-old daughter getting vaccinated surely ruffled some feathers amongst the anti-vaccination community. A recent Time article discusses the fact that this isn’t the first public statement that Zuckerberg has made regarding vaccinations. He recently used Facebook to publicize a book called On Immunity, by Eula Bliss. “The science is completely clear: vaccinations work and are important for the health of everyone in our community,” he wrote.

Despite the fact that links between vaccines and autism have been discredited, there are still many who believe that vaccines are harmful. But what about the harm caused by unvaccinated individuals who are spreading diseases that were once a thing of the past? Indeed, if Zuckerberg wanted to, he could shut down the Facebook pages of the “antivaxxers.” This does not violate any First Amendment rights, due to the fact that Facebook is a private company.

Another article on the Time website discusses the dangers of “tolerating” those who refuse to vaccinate their children. Recently, at a school in Melbourne, Australia, approximately a quarter of the school’s student body contracted chicken pox. Only 73.2 % of the students had been vaccinated.  Apparently, the school does not require students to receive vaccinations, and instead wrote that “staff respects the right of every family to make choices about immunisation,” in a school newsletter back in May.

While tolerance is often a good thing, even called “the social and intellectual flexibility that allows a society to function at all,” at what cost does it come? Will our society eventually see a dangerous return of diseases that until recently have been kept at bay due to vaccines? The line has to be drawn somewhere, especially when the beliefs of certain individuals (despite the scientific facts) negatively impact those around them.

Measuring Medicine and Evaluating Education

by Jen Jenkins

The ability to measure quality in nearly every industry has proven to be a powerful and important component for success. In both healthcare and education, metrics and measurements are no less significant, but over time has this number gathering trend spun out of control?

According to Robert Wachter, a professor and chairman of the Department of Medicine at UC San Francisco and the author of this New York Times blog post, in healthcare and education “the focus on numbers has gone too far.” In medicine, the constant measuring that takes place has become more a matter of being included on a “top 100” or “best hospitals” list, rather than a chance to improve patient care. A significant amount of a doctor’s precious time is now being spent entering information into a computer system instead of having quality conversations with patients. A study done in 2013 found that during a 10-hour shift, emergency room doctors were clicking a mouse 4,000 times. That is an immense amount of time spent entering information and being away from patients, all in the name of producing numbers.

It’s true that spending time on metrics is not as much of an issue in industries where the focus and care of another person doesn’t possibly mean life or death.  The issue isn’t whether or not to get rid of measurement in healthcare–it does play an important role–but to instead scale it back. Allowing time for more research could help produce a better understanding of what to measure and ensure that what is being measured really matters in terms of the betterment of the industry. Overall, according to Robert Wachter, one should fully appreciate that measurement does place a burden on professionals in the medical field. We need to learn how to minimize that burden so that measuring for quality does not mean a decline in the actual quality of care that patients receive from doctors.

In his post, Robert Wachter goes on to explore this phenomenon of metrics and measurement in another industry where the cons may outweigh the pros. As in medicine, measurement in education comes at an expense. According to educators, that expense is actual learning and a loss of some important subjects that are not as easily measured by tests – examples include art, music, and physical education. Is a preoccupation with test scores really worth the demise of a well-rounded education?

Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, had a surprising answer regarding the secret behind quality. After a lifetime spent in the field of quality measurement, this data-driven scientist said, “The secret of quality is love.” It’s clear that we cannot let the business side of either healthcare or education dissuade people from becoming doctors or educators; these are both fields that should be able to adopt measurement without losing the compassion and altruism that exists at their core.

Why the Age of Your Doctor May Matter

by Angela Sams

If you need some sort of serious medical procedure done or find yourself in the hospital for another reason, you would probably want the best, most experienced doctor, right? To the contrary, a recent New York Times op-ed article by Dr. Ezekiel Emanuel indicates that the opposite may be true. The article explores a recent research paper published in JAMA Internal Medicine, which analyzed ten years of data regarding hospital admissions. The research shows “that patients with acute, life-threatening cardiac conditions did better when the senior cardiologists were out of town.” This was the case at what are considered “the best hospitals in the United States, our academic teaching hospitals.” When the top senior cardiologists were absent, patients’ mortality was decreased by approximately one third. Furthermore, patients whose heart conditions are treated in a teaching hospital rather than a community hospital generally fare much better.

One would think that an older, more experienced doctor would be more adept at treating patients, but Dr. Ezekiel poses the idea that younger doctors are still fresh from training and may be better at clinical treatment, whereas older doctors are better at the research side of medicine. Senior doctors may also be more likely to try more interventions. The data in this recent paper, along with other recent studies, seem to indicate that less is better in terms of healthcare. It’s important to remember that with each new test or treatment comes the potential for side effects or something going wrong.

Perhaps doctors should be required to give patients information about a potential procedure and prevent over-medication by attempting to discontinue medications annually. Dr. Ezekiel suggests that patients can also become involved in their own care by asking four simple questions before a procedure:

  • What difference will it make, and will the test results change the treatment approach?
  • How much will this treatment improve the prolongation of my life and reduce the problem?
  • How likely and severe are the side effects?
  • Is this a teaching hospital?

Patients have a right to be as involved as possible in their care. And, while it may make a doctor uncomfortable to be asked such questions, if they truly have the best interest of the patient at heart, they will be more than happy to answer.

Dangerous Risks of Using Opioids to Treat Pain

by Angela Sams

Have you ever been prescribed a painkiller to help with surgery recovery or maybe for back pain that just won’t go away? Even if not, it is likely that you know someone who has been on a painkiller medication at some time or another. That likelihood rose steadily between 1999 and 2010, as doctors began turning to a “quick fix” that will treat their patients in an aggressive manner. But, as patients cooperatively swallow their prescribed pills, it is important to consider the downsides of opioids on an individual and societal level.

A recent opinion article in the New York Times indicates that while there has been a “steady increase in the mortality rate of middle-aged white Americans since 1999,” this is not the case in other age and ethnic groups, or even with people in the same age group who live in other countries. Consider this disturbing statistic: “In 2013 alone, opioids were involved in 37 percent of all fatal drug overdoses.” It is clear that opioid overdose is quickly becoming an epidemic, and a major shift in attitude is a key to the problem.

At one time, opioids were used mainly for pain caused by terminal illnesses or as a short-term fix for pain after surgery. However, during the 1990s, drug companies began marketing to doctors, encouraging them to “be proactive with pain and treat it aggressively.” Afraid of being seen as uncaring or reprimanded for not treating a patient’s pain to the best of their abilities, doctors fell for the marketing scheme and began prescribing powerful opioids such as OxyContin.

Though opioids may relieve pain and help a patient recover more comfortably, evidence suggests that they should only be used for short-term treatment, not long-term treatment of nonmalignant pain.  There are also many downsides to taking such a medication. This type of painkiller is extremely addictive, may affect mental health, lead to unemployment, and cause poor health in general, to name a few risks. Ironically, using these drugs can also make a patient more sensitive to pain.

So what is the solution to this problem? Should people suffer in pain, rather than take the risks associated with opioid drugs? Actually, the answer may be as simple as taking an over-the-counter medication. In one study, researchers found that when Motrin and Tylenol were combined, they were actually more effective than opioids, not to mention safer. While opioids are still very readily available to patients who are in pain, small steps towards a solution have been taken. For example, the Food and Drug Administration issued a Risk Evaluation and Mitigation Strategy, ensuring that opioids now contain warning labels. The makers of these drugs must also give training and education that will help doctors prescribe them safely. Certainly, patient awareness is helpful, but only time will tell if physicians can turn this shift in attitude back around, and work towards other, safer solutions for pain management.

Restoring Sight to the Poor

by Angela Sams

Can you imagine a life without sight? Those who are blind face many challenges on a daily basis—challenges that probably don’t even occur to those who can see. Enter Dr. Sanduk Ruit, a Nepali ophthalmologist who is on a mission to help the blind see, using a procedure called the “Nepal Method.” A recent article in the New York Times delves into his miraculous work.

Living blind in a country that is poor presents its own unique challenges, as access to healthcare may not even be an option. Dr. Ruit is pushing past these barriers by offering a cataract microsurgery to patients for only $25. It is a technique that he developed, and it is now being taught to medical students in the United States.

For the powerful impact the microsurgery has on its recipient, you would think it wouldn’t be so simple. That could not be further from the truth. The entire process takes about five minutes, and involves removing the cataract on a patient’s eye and replacing it with a new lens. A procedure that was once seen as something that could only be done with expensive machines, Dr. Ruit’s procedure is just as effective. The big difference is that it is much more affordable.

The cure for blindness extends beyond Nepal. A charity called the Himalayan Cataract Project helps ensure that other countries such as Ethiopia and Ghana can also benefit. The charity was started by Dr. Geoffrey Tabin, another eye specialist who has been working next to Dr. Ruit in Nepal.

In addition to removing the cataracts of the blind, Dr. Ruit founded the Tilganga Institute of Ophthalmology, which includes “hospitals, outreach clinics and training programs and an eye bank, using fees from better-off patients to support impoverished ones.” Approximately 30,000 patients will receive eye surgery from the institute annually.

It seems that the success in Nepal is just the beginning of something great. Stories such as this give us reason to believe that blindness can eventually be eradicated, one eye at a time.

 

And The Nobel Prize Goes To…

by Jen Jenkins, Market Analyst

Three scientists have received the prestigious award this year for what the Nobel Prize committee said were “therapies that have revolutionized the treatment of some of the most devastating parasitic diseases.”

Dr. William Campbell, Dr. Satoshi Omura and Dr. Tu Youyou are the recipients of the award; the doctors originate from Ireland, Japan, and China respectively. Dr. Campbell and Dr. Omura collaborated, as well as worked on independent aspects, to develop the medicine Avermectin and will share one half of the prize money; Dr. Tu will claim the other half of the money for the medicine Artemisinin, her discovery of which was inspired by traditional Chinese medicine.

Parasitic diseases threaten approximately one-third of the world’s population today, especially in the poor areas of Africa, South Asia, and Latin America. These two newly developed medicines address the parasitic diseases transferred to humans from black flies and mosquitoes and have been included in the World Health Organization’s list of essential medicines. Both medicines are distributed to areas in need either for free or at very low cost.

“These two discoveries have provided humankind with powerful new means to combat these debilitating diseases that affect hundreds of millions of people annually. The consequences in terms of improved human health and reduced suffering are immeasurable” because parasitic diseases “represent a huge barrier to improving human health and well-being.”

-The Nobel Committee, as reported by The New York Times

Read more in depth about these fascinating scientists, their discoveries, what led to their discoveries in this New York Times article.

A Complicated System

by Jen Jenkins, Market Analyst

In this article, Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University School of Medicine, provides an anecdotal reference to something that is too often overlooked within the American health care system. Issues about the affordability of obtaining insurance and the quality of care are constantly highlighted and debated, but how care is actually delivered is an issue all on its own.

The Affordable Care Act was passed in an effort to ensure a significant decrease in the number of people who did not have insurance. Regardless of where you stand on the topic, the fact is that having insurance is only one access point within the American health care system. What happens after you have insurance? What is the process of receiving care actually like?

In the aforementioned article, Dr. Carroll describes his difficult journey with ulcerative colitis and the obstacle of every three months obtaining the only medicine that has ever worked for him. Just reading his account is frustrating and confusing. He ends this anecdote with wonder at how the majority of people, especially anyone suffering worse problems than his, could possibly manage the often dizzying twists and turns of correlating insurance protocols, with doctor’s visits, with lab testing, with pharmaceutical companies, and more.

Reform in the medical world is long, difficult road. The Affordable Care Act was  a vehicle to get more people health insurance and it is still being vehemently argued. Once that piece of the puzzle is solved in some capacity then maybe we can look further into reforming the actual system and access to the care that is delivered.