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The Practice of Medicine

The Downside of Doctors Who Feel Your Pain

From an editorial in The New York Times: “Medicine, like education, business and fashion, is subject to fads. Hormone replacement therapy. Radical mastectomy. Bloodletting. The latest? Breeding nice doctors. It’s all the rage.”

The author notes that “proponents of weeding out students who lack interpersonal skills argue that communication errors are at the root of medical mistakes. But we have no data to suggest that medical students who sit close but not too close make any fewer mistakes than their less-communicative colleagues. The awkward student in the corner who obsessively follows a checklist may make fewer procedural mistakes than his charming friend who lights up the room.”

It’s a thought provoking read and a good reminder that medicine, as with everything else, has its trends but unlike other fads is subject to the rigors of scientific investigation. “In a culture that values novel technology above all else, undue emphasis on interpersonal skills may make it only more difficult for patients to discern good medicine from that which makes us feel most understood. ” Read more…

Scientists Retreat on Chronic-Fatigue Theory

Articles in the The Baltimore Sun and The Wall Street Journal are significant in a number of ways. With respect to the matter of an infectious cause of chronic fatigue, they would suggest that prior theories and findings in support of this may lack foundation. This would support other etiologies including psychogenic.

 On a broader note, the trail of study as summarized shows how science as a discipline works. Hypotheses are generated. Studies test the hypotheses and support or refute them. Studies are replicated and the process can be repeated in various permutations. Scientists are willing to be disproven and will let the data decide their positions.

Science, while imperfect, is a process and system of inquiry and openness to let the outcomes speak for themselves.  

There are many people who believe they suffer from chronic fatigue. See http://www.cfids.org/. At this site one finds great interest in the research (http://www.research1st.com/2011/09/13/the-x-factor/).One can’t question the suffering of those in pain. It should be interesting to observe how changing scientific views impact individuals’ views and interpretation of the meaning and origins of their  pain.

The Right Way to Help Veterans(?)

This article in The Seattle Times, “Seattle, King County to Set up Special Veterans Courts,” caught our eye as an interesting follow-up to an MCNtalk posting a few weeks ago, “The Wrong Way to Help Veterans.” 

The New York Times op ed piece which inspired our first posting on the subject of veterans and the mental health system noted that “as many as 20 percent of them will suffer from post-traumatic stress disorder, anxiety or depression, while suicide rates have reached tragic new highs among veterans.”

The Seattle  Times article notes that Seattle will open a special court Sept. 20 for military veterans charged with nonviolent crimes, and King County may not be far behind. Veterans Court, part of Seattle Municipal Court, is intended to give some vets charged with misdemeanor offenses a chance to obtain substance-abuse and mental-health treatment while still being held accountable for their actions, according to court officials.

“Providing a specialized court experience for veterans is a logical extension of the services already available in Mental Health Court and Community Court,” City Attorney Pete Holmes said in a news release. “My office is dedicated to ensuring that veterans will be held accountable for misdemeanor crimes, but in the supportive environment they deserve.”

Veterans courts, the latest kind of therapeutic specialty court, have sprung up in 80 jurisdictions since the concept was pioneered by Buffalo, N.Y., in 2008. Four Washington counties — Clark, Pierce, Spokane and Thurston — have such courts.

The comments posted on-line about The Seattle Times article are decidedly mixed, ranging from those who are opposed to separate treatment for veterans to those objecting to soldiers serving multiple tours of duty to those who believe that this type of court is a step in the right direction in addressing the problem. And then there’s the practical view: “Now that’s something which is long over due, is needed and will keep down incarceration costs and other costs of care.”

Read more…

Medicine on the Move

In an era of rapidly rising health care costs and consumer concerns over diminished coverage, it’s encouraging once in a while to take note of positive, transformative changes in the health care industry. This article in The Wall Street Journal summarizes a few innovations:

  • Vscan (an $8,000 device) a portable ultrasound device roughly the size of a cellphone.
  •  “Invisible bracelet”: In the example given, each morning a woman clips a  red plastic tag to her daughter’s shirt each morning. One side of the tag reads: “In Case of Emergency.” The other instructs responders to text a unique PIN to the number 51020. Anyone who does so will receive a text offering detailed instructions for her daughter’s care. They’ll learn, for instance, that her particular form of epilepsy does not respond well to the most common seizure drugs and that certain medications make her manic.
  • a wireless ambulance-monitoring system: a small video camera, digital stethoscope and microphone mounted on a stretcher transmits live images of the patient to the treatment team waiting in the hospital emergency room.
  •  Mobile MIM system (approved last February by the Food and Drug Administration), which lets doctors use their iPhones to view images from sophisticated hospital tests such as MRIs and CT scans.
  • AirStrip OB: An iPhone application which, with a couple of taps, allows a physician to view, in real-time, all the data from the sensors strapped to a  patient’s abdomen.

So much information, so readily available, can have a downside. “We could create a whole culture of cyberchondriacs,” says Dr. Topol, a cardiologist in San Diego. He acknowledges, too, that something will be lost when most face-to-face visits with physicians are replaced by wireless exchange of data. “We’re getting virtual touch, rather than actual touch,” he says.

But Dr. Topol says in his own practice, he’s found that many patients are more willing to make lifestyle changes that keep them healthy when they can monitor the consequences of their actions in real time. A doctor can talk “until he’s blue in the face,” he says, but it sometimes takes cold, hard data to motivate a patient. Read more…

The Wrong Way to Help Veterans

At MCNtalk we found this Op Ed piece in The New York Times to be particularly poignant. Firstly, it reminds us, as we enter the tenth year of armed conflict, of the very real and tragic cost of war. It is after all our war, and on our behalf that people — Americans and Afghanis both — are suffering: “If all goes according to plan, by the end of the year, 10,000 American soldiers in Afghanistan will be home with their families — and their memories. As many as 20 percent of them will suffer from post-traumatic stress disorder, anxiety or depression, while suicide rates have reached tragic new highs among veterans.”

Additionally, for MCN it reminds us of the human, and very complicated, side of the IME business, that of determining causality and disability: “After all, gauging the prognosis of mental injury in the wake of war is not as straightforward as assessing a lost limb. What’s more, it is very difficult to predict the pace and extent of a patient’s progress when the odds of success also depend heavily on non-medical factors: the veteran’s own expectations for recovery, availability of family and social support, and the intimate meaning the patient makes of his or her distress, wartime hardships and sacrifice.”

And reminds us in the IME business of what we don’t do for claimants—provide direct treatment: “Instead, Veterans Affairs should adopt a treatment-first approach. The sequence would begin with treatment, move to rehabilitation and then, if necessary, assess a patient for disability status, should meaningful functional deficits persist.

“At the same time, veterans too fragile for employment while in intensive therapy and rehabilitation—which, for some, could last up to a year—should receive financial support. Not disability payments, mind you, with their specter of permanent debilitation; call it a ‘recovery benefit’—as generous as total disability, but temporary.

“With some exceptions, it is both realistic and important to instill the expectation in veterans that they will get better and find a comfortable and productive niche within the community and family. The road home from war is already an arduous one — the mental health system shouldn’t make it any longer than it already is.”

And of course we  found this piece to be refreshing because the author not only outlines a problem, she attempts to find a solution while neither ignoring nor minimizing the factors involved. Read more…

Cuts in Health Care May Undermine Role in Labor Market

Per this New York Times article, “even during months of stubborn unemployment, the health care industry has provided a solid underpinning, reliably adding jobs in an otherwise dismal environment.”

Is this good news? Generally “reliably adding jobs” sounds nice. But the article concludes by quoting Joshua Shapiro, chief United States economist at MFR, Inc. (Global Economic Consultants): “If spending on health care continues at its current pace, it will choke out other vital sectors and end up hurting the rest of the economy. I think the path that we’re on now is clearly unsustainable.”  

One of the justifications for the high cost of health care as a component of GDP in the US is that it creates jobs. On a macroeconomic level, this may be the case, but at what cost. And what will the outcome be if and when costs moderate due to political or budgetary mandates. How many hospitals are built on the funds provided by Medicare and what power does this spending yield? A recent posting  on MCNTalk focused on tremendous discounting and write-off from list price of a Medicare bill. Presumably this example precedes additional pending Medicare cuts under consideration.

Not discussed in the article is the impact of cost shifting  to the private sector, including most significantly the private group health insurance market, as well as other systems including workers’ compensation, accident related care and other areas that are not under Federal pricing guidelines. If cost shifting is inevitable and significant, as we predict it will be, rational employers and payers will continue to decrease their contributions to their employees’ healthcare, leading to a higher likelihood of a national health payment scheme, as many are hoping for but significant constituencies have to date defeated.

Read more…

Guarding Privacy / Protecting Patients

At MCNtalk we thought this posting in the New York Times “Views,” Guarding Privacy May Not Always Protect Patients, was an interesting read.

“Juggling parental concernwith an adolescent patient’s legal and ethical right to privacy,” the author, Dr. Perri Klaas notes,  “opens up some tricky questions.”

The law varies state by state, but many, including New York, allow minors to consent by themselves to medical care involving such sensitive needs as contraception, pregnancy, sexually transmitted diseases, and mental health.

Clinics for adolescents are keenly conscious that the promise of confidential care is essential to gain and hold their young patients’ trust. But in those same clinics, doctors often try to convince teenagers to bring parents into the conversation. Read more…

Affordable, High-Quality Health Care

4,000 patients in the Seattle area buy their primary care directly from a group of three clinics called Qliance Medical Group, as noted in this Bloomberg Businessweek article. In exchange for monthly fees between $50 and $130—depending on age—Qliance patients can see their doctors as often as they want.

After 10 years of running his own small practice, founder Garrison Bliss opened the first Qliance clinic in Seattle in 2007, which he envisioned as the start of a national network. Now his three clinics have eight doctors and two nurse practitioners. None handles more than 800 patients.

  • The model eliminates the cost of collecting money from insurers, which Qliance says can eat up $16 of a $60 payment for an office visit, or more than a quarter of a practice’s revenue.
  • Qliance doctors’ income isn’t tied to the number of procedures they do, so they see fewer patients and spend more time with them.
  • Patients’ monthly fees cover preventive care, basic tests, advice, treatment for chronic conditions, and simple emergency procedures such as stitches and X-rays.
  • Patients still have to pay for prescriptions, specialists, and hospital expenses. Most have insurance to cover at least some of those costs.
  • According to the company, Qliance patients make fewer trips to hospitals and specialists because of the more attentive primary care and incur 22 percent less in medical costs annually than average.
  • Qliance has raised $13.5 million from the likes of Jeff Bezos and Michael Dell to bring its brand of affordable, high-quality primary care to cities across the country.

Bliss believes the model could help reduce health-care costs nationwide: “We see this as an enormous, almost unlimited marketplace,” he says. Read more…

Breast Cancer & Avastin Approval

This is fascinating New York Times article that underscores a number of challenges:

While drug use should be based upon data, interest groups and patients are trying to influence public policy and drug approval in a heart-wrenching set of personal appeals.

The FDA has a mandate to respond to data. In this situation they appeared to hurry approval and study the data later. Such study did not support the approval for this application of a very expensive drug. The cost of this and other treatments is predominantly not paid for by the patient or their family but rather by taxpayers and employers and employees who fund private insurance, Medicare, Medicaid, the Veterans Administration – the major payers for health care.

Should we collectively pay for the wishes of hopes of others when quality data does not appear to support such expenditure? And how much of the price of such medications and other treatments is influenced by the disconnect between the payer and the consumer? How many treatments of questionable value would be deferred if individuals felt the impact personally, and how would prices differ paid for by the consumer/patient rather than someone else?

The moral hazard dilemma of insurance if evident in stories like this: Originally intended to help people afford unexpected expenses due to significant health matters, health insurance has evolved or devolved into payment for normal expenses like eyeglasses, routine physicals, contraception and the like. Health inflation is markedly impacted by the market disconnect between buyer and payer, and legislation has forced payment of questionable services and professionals in many jurisdictions. Whether this was envisioned when insurance became common is not clear, but it certainly is what we now have. Read more…

As Physicians’ Jobs Change, So Do Their Politics

At MCNtalk, we try to stay away from political discussion,  but we thought this article in the New York Times was interesting as it highlights some potential shifts in the medical profession. Specifically, “Doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.”

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states. And why is this important?

  • As the article notes, that change could have a profound effect on the nation’s health care debate.
  • Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.

Read more…