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Dr. George Lundberg: A Fine Choice For Surgeon General

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Rumor has it that Sanjay Gupta is no longer in the running for the office of Surgeon General. Many people had voiced their concerns about his potential nomination (including Paul Krugman, Maggie Mahar, Gary Schwitzer, Dr. David Gorski, and myself) and it looks as if his lack of experience or training in matters of public health, along with a history of industry ties has put the kabosh on his nomination.

So who will be our next Surgeon General? It’s hard to say, but a petition is circulating on behalf of Dr. George Lundberg – a fine nominee for the position in my opinion. Let me explain why.

A review of Dr. Lundberg’s curriculum vitae easily establishes his professional qualifications for the position. Not only has he been one of the longest standing Editors-In-Chief of all the American Medical Association journals (including JAMA), and the founder of the world’s first open-access, peer reviewed online medical journal (Medscape Journal of Medicine) but has served in an advisory capacity to everyone from the World Health Organization, to AHRQ, the Joint Commission, Harvard’s School of Public Health, the Department of Health and Human Services, Food and Drug Administration and the Surgeon General of the US Navy. He is also a prolific and influential writer, having authored 149 peer-reviewed articles, 204 editorials, and 39 books or book chapters. Dr. Lundberg has a large and devoted national and international audience and is highly esteemed by all who know him.

Dr. Lundberg has provided editorial leadership since the mid 1980s in American healthcare reform, campaign against tobacco, prevention of nuclear war, prevention and treatment of alcoholism and other drug dependencies, prevention of violence, changing physician behavior, patient safety, racial
disparities in medical care, health literacy, and the ethics of medical publishing and continuing medical education.

However, what may not be obvious from Dr. Lundberg’s list of extraordinary accomplishments, is his extraordinary character and wisdom. I had the privilege of working with George at the Medscape Journal of Medicine and reported directly to him. From this vantage point I was able to to observe his impartiality, his commitment to honesty and integrity, and his ability to walk the line between inclusivity of opinion and exclusivity of falsehoods. George is a defender of science, a welcomer of ideas, and an impartial judge of content. He can capture an audience, nurture imagination, and see through deception. George is exactly the kind of person we need as Surgeon General – he can be relied upon to discern truth, and maintain his faithfulness to it under political or industry pressure.

But best of all, George understands the central role of trust in healthcare. In his recent book, Severed Trust, George analyzes the policy decisions that have shaped our current healthcare system, and laments their inadvertent collateral damage: the injury to the sacred trust between physicians and patients.

If we want to come together as a nation to restore hope and trust in America – and we want to create an equitable healthcare system that leaves none behind, restores science to its rightful place, and heals the wounds endured by both providers and patients, then we need a Surgeon General like George Lundberg to help us.

I can only hope that his candidacy will be given the full consideration it deserves.

Why Non-Scientists Should Not Direct Scientific Efforts: Senator Harkin’s Misguided Beliefs Exposed

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I’ve been blogging a lot recently about the problems caused by health policy makers who don’t appear to understand medicine or science. I’ve also been lamenting the relative lack of physician input at the highest level of health reform. But today I’d like to present a prime example of the perfect storm in health policy: when willfulness, ignorance, and magical thinking combine to push an agenda despite billions of tax payer research dollars proving the futility of such efforts.

In this video, Senator Tom Harkin describes the impetus behind the creation of the National Center for Complementary and Alternative Medicine (NCCAM). Harkin suggests that he single-handedly introduced legislation in 1992 that created the Office of Alternative Medicine at the National Institutes of Health (NIH). This office paved the way for an entire new branch of research at NIH devoted to exploring the potential validity of non-science based medical practices such as homeopathy, acupuncture, traditional Chinese medicine, energy healing, meditation and more. He introduced the legislation because a friend of his experienced a substantial health improvement after trying one of these non-science based therapies. Essentially, an entire branch of the NIH was founded on an anecdote.

What’s worse is that after a decade of careful analysis of these alternative therapies, science has shown that not a single one of them appears to be efficacious beyond placebo. One would think that Senator Harkin would be embarrassed by the colossal waste of tax payer resources spent on this pet project of his. But no, instead he chastises the scientists who did the research, saying that they had failed to do their job of “validating” the therapeutic modalities. Wow. I guess he was never interested in finding out the truth about what works and what doesn’t – because when objective analysis reveals that these modalities don’t work, then the science must be flawed.

Now don’t get me wrong – healthy eating, regular exercise, emotional and psychological support are critical factors in good healthcare, and I fully believe that America needs to become a “wellness culture” in order to prevent chronic diseases and improve quality of life. I also believe that Americans are often over-treated and over-medicated when lifestyle interventions might be their best treatment option. However, in encouraging behavior modifications, we don’t need to foist placebo therapies on them under the banner of science. The problem with “integrative medicine” is that it takes some good medical principles and infuses them with scientifically debunked and outdated systems of thought (debunked repeatedly by NCCAM, the very scientific body that Harkin hoped would validate them.)

What we really need to do is stop splitting the practice of medicine into “integrative” vs “non-integrative” and simply follow scientifically vetted best practices. Patients need a comprehensive approach to their health, a medical home with a good primary care physician coordinating their care, reliable health information to support their decision-making, a strategy to eat well and exercise regularly, and mental health services as needed.

Senator Harkins’ plan to continue flogging the alternative medicine “dead horse” is not helpful – it’s not good science, and it’s not a good way to spend our tax dollars. I can only hope that one of the positive effects of Comparative Clinical Effectiveness Research will be to put an end to the promotion of the ineffective therapies that Harkin fervently hoped would be validated. I also hope that the new Federal Coordinating Council will not support funding to pet projects that are founded upon anecdotes, pseudoscience, and wishful thinking. Now more than ever we need good science underpinning our healthcare spending, and we need informed scientists advising our government on priorities for America’s health.

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Addendum:

More outrage from the medical blogosphere over Harkin’s views:

1. Dr. David Gorski:  Senator Tom Harkin: “Disappointed” that NCCAM hasn’t “validated” more CAM

2. Dr. Peter Lipson: Harkin’s War On Science

The AMA And Congress: How To Cross The Cultural Divide

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The AMA’s communications department kindly sent me a copy of a letter that they (and 9 other professional society CEOs or Presidents) recently sent to Barack Obama and 12 members of congress. I’ve been blogging about the fact that healthcare providers in general, and physicians in particular, do not seem to have much of a voice in healthcare policy. In fact, from what I can tell, Dr. Nancy Nielsen is carrying the torch almost exclusively. I don’t mean to belittle anyone’s efforts, it’s just that I’ve noticed that she is often the only physician at the highest level policy meetings.

So it was with great interest that I read the group letter to Obama et al., wondering what collective message our physician leaders were trying to get across. The writing was academic – using terminology familiar to those heavily steeped in medicine – and emphasized the creation of a patient-centered culture supported by evidence based medicine.

However, the letter raised an interesting question in my mind: Will members of congress read and understand it? I believe that the most effective letters to congress are likely to share three qualities: 1) they must be emotionally provocative 2) they must be written at about the 6th grade reading level 3) they must be brief.

Why Letters Must Appeal To Emotion (“Cultural Competency”)

Dr. Nielsen said at a recent Medicare Policy Summit that speaking with Senators can be “pure theatre.” That has been my observation as well. Decades of experience speaking in large committee meetings have taught them that amusing sound bites or emotional outbursts get attention. In fact, it may be the best way to get things done in congress. For example, did you know that the reason why kidney care is the only disease-based eligibility under Medicare is that Shep Glazer testified before congress during one of his dialysis sessions?

Washington , D.C. , Nov. 4, 1971 – In the most dramatic plea ever made on behalf of kidney patients, Shep Glazer, Vice-President of NAPH, testified before the House Ways and Means Committee while attached to a fully functioning artificial kidney machine.

Minutes before, in the corridor outside the hearing room, Shep told reporters from the AP, UPI, and the Washington Post, “Gentlemen, I am going to tell the Committee that if dialysis can be performed on the floor of Congress, it can be performed anywhere.” As his wife, Charlotte , connected him to the machine, he continued, “Kidney patients don’t have to be confined to hospitals, where expenses are $25,000 a year and more per patient. It’s much cheaper in a satellite unit or at home. I want to show the Committee what dialysis is really like. I want them to remember us.”

My point is that in congress, as opposed to medical meetings, emotion is king. Physicians have a hard time speaking from the gut, since we’re trained to speak from data – because we know that the gut can be misleading. However, my plea to physician groups is this: let’s collect our data, understand the science behind our point of view, and then present our advice in a way that is persuasive to congress. That means we’d probably benefit from a few theatre classes (can we get CME credit for them?) I’m not suggesting that we become undignified in any way – I’m just saying that personal stories, case studies, and appeals to emotion are the currency on the Hill. If we want attention, we’ll need to find a way to make our points in their own language.

For example, I was listening in to a recent Senate hearing on healthcare finance, when a Republican senator began his introductory remarks about “out of control spending” with this:

I must tell you that I have major concerns about our current approach to spending. We’ve already sunk billions of dollars into all kinds of bailouts and programs without any clear benefits. But every time I bring up the excessive spending issue, you’d think I was a skunk at a picnic…

An amusing analogy, and one that resonated with his peers. This Senator understood the culture to which he was speaking. In other words, he had a “culturally competent” message.

Why Letters Should Be Written At About The 6th Grade Reading Level (Health Literacy)

Dr. Richard Carmona told me that one of the first things he learned as Surgeon General was that the American people understand health information at a 6th grade reading level. Thus, there is no point in making a 100+ page medical report on the health hazards of smoking the corner stone of a public smoking cessation campaign.

Health information must be written in a clear, and actionable manner – but it must also be delivered in such a way that it resonates with diverse communities. Letters to congress are no different – many of our congressmen and women do not have advanced medical or science degrees. We must be sensitive to that and write to them in a way that makes it easy for them to understand what we’re hoping to accomplish.

Why Letters Must Be Very Brief

Much has been made of the fact that many people who signed the recent 1000+ page stimulus bill hadn’t actually reviewed it. In fact, it is estimated that 306 members of Congress voted for a bill they had not read.

Of the 535 members of the United States House and Senate,  246 House members and 60 members of the august Senate voted for the $787 billion  stimulus bill without having read a single one of the bill’s 1,071 pages or having any idea of where all of this money borrowed from our grandchildren is going to be spent.

So if our members of Congress don’t read the stimulus bill, will they take the time to read long letters from professional societies? I think you know the answer.

Conclusion

The AMA should be applauded for their lobbying efforts on the part of physicians in Washington. However, my personal view is that letters to congress may be more effective if they are written in a concise, jargon-free, compelling way that respects the “culture” of congress. We physicians hear a lot about “health literacy” and “cultural competency” – and must remember to apply those principles to letter-writing campaigns.

Will any letter influence congressional decision-making? It’s hard to measure the “ROI” of group letters to congress – and certainly they’re only one part of a larger strategy. However, it behooves us physicians to find ways to reach across the cultural divide to speak to congress about the issues that trouble us all: the fate of patients. Letters may be helpful, but an increased presence in Washington, along with some heartfelt reasoning, may be our best shot. Perhaps the Broadway actors affected by the economic recession could help us out?

Attention Health Policy Makers: How To Win Docs And Influence Patients

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carnegie_smallPretty much everyone agrees that we need to improve the quality of healthcare delivered to patients. We’ve all heard the frightening statistics from the Institute of Medicine about medical error rates – that as many as 98,000 patients die each year as a result of them – and we also know that the US spends about 33% more than most industrialized country on healthcare, without substantial improvements in outcomes.

However, a large number of quality improvement initiatives rely on additional rules, regulations, and penalties to inspire change (for example, decreasing Medicare payments to hospitals with higher readmission rates, and decreasing provider compensation based on quality indicators). Not only am I skeptical about this stick vs. carrot strategy, but I think it will further demoralize providers, pit key stakeholders against one another, and cause people to spend their energy figuring out how to game the system than do the right thing for patients.

There is a carrot approach that could theoretically result in a $757 billion savings/year that has not been fully explored – and I suggest that we take a look at it before we “release the hounds” on hospitals and providers in an attempt to improve healthcare quality.

I attended the Senate Finance Committee’s hearing on budget options for health care reform on February 25th. One of the potential areas of substantial cost savings identified by the Congressional Budget Office (CBO) is non evidence-based variations in practice patterns. In fact, at the recent Medicare Policy Summit, CBO staff identified this problem as one of the top three causes of rising healthcare costs. Just take a look at this map of variations of healthcare spending to get a feel for the local practice cultures that influence treatment choices and prices for those treatments. There seems to be no organizing principle at all.

Senator Baucus (Chairman of the Senate Finance Committee) appeared genuinely distressed about this situation and was unclear about the best way to incentivize (or penalize) doctors to make their care decisions more uniformly evidence-based. In my opinion, a “top down” approach will likely be received with mistrust and disgruntlement on the part of physicians. What the Senator needs to know is that there is a bottom up approach already in place that could provide a real win-win here.

Some 340 thousand physicians have access to a fully peer-reviewed, regularly updated decision-support tool (called “UpToDate“) online and on their PDAs. This virtual treatment guide has 3900 contributing authors and editors, and 120 million page views per year. The goal of the tool is to make specific recommendations for patient care based on the best available evidence. The content is monetized 100% through subscriptions – meaning there is no industry influence in the guidelines adopted. Science is carefully analyzed by the very top leaders in their respective fields, and care consensuses are reached – and updated as frequently as new evidence requires it.

Not only has this tool developed “cult status” among physicians – but some confess to being addicted to it, unwilling to practice medicine without it at their side for reference purposes. The brand is universally recognized for its quality and clinical excellence and is subscribed to by 88% of academic medical centers.

In addition, a recent study published in the International Journal of Medical Informatics found that there was a “dose response” relationship between use of the decision support tool and quality indicators, meaning that the more pages of the database that were accessed by physicians at participating hospitals, the better the patient outcomes (lower complication rates and better safety compliance), and shorter the lengths of stay.

So, we already have an online, evidence-based treatment support guide that many physicians know and respect. If improved quality measures are our goal, why not incentivize hospitals and providers to use UpToDate more regularly? A public-private partnership like this (where the government subsidizes subscriptions for hospitals, channels comparative clinical effectiveness research findings to UpToDate staff, and perhaps offers Medicare bonuses to hospitals and providers for UpToDate page views) could single handedly ensure that all clinicians are operating out of the same playbook (one that was created by a team of unbiased scientists in reviewing all available research). I believe that this might be the easiest, most palatable way to target the problem of inconsistent practice styles on a national level. And as Senator Baucus has noted – the potential savings associated with having all providers on the same practice “page” is on the order of $757 billion. And that’s real money.

I highly recommend a bottom up approach, not top down. That’s how you win docs and influence patients.

Another Example Of Good Medicine That Does Not Follow “Protocol”

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As far as I can tell, there are very few physicians currently involved in the innermost circles of healthcare reform. This is concerning to me, not because I’m one of those “paternalistic doctors” who “drive up in their Porsches threatening to pull out of Medicare” but because I think that many policy makers don’t really understand the incredible complexity associated with doing the right thing for patients. Here is an excerpt from the WhiteCoat’s Call Room blog that perfectly illustrates why practicing good medicine often requires a break from protocol:

It isn’t just the patients who think I’m a bad doctor.

Based on the information from all the pinheads at Medicare’s “HospitalCompare” web site, I’m downright dangerous.

For those who don’t know about Hospital Compare, it is a site where the general public can compare the “quality indicators” for hospitals on measures deemed important by the AHRQ.

I failed to meet a couple of indicators recently, so I received notices from our hospital administration that I am now considered out of compliance with the HospitalCompare guidelines and am bringing down our numbers on the HospitalCompare.gov web site.

In other words, Medicare thinks I’m a bad doctor.

Let me tell you about the patients I screwed up on.

The first patient was a gentleman in his 70’s who started having chest pain at home. He got sweaty, passed out, and hit his head on the concrete floor in his house, causing a nice goose egg on the back of his noggin. When he arrived in the emergency department, he was still having chest pain, so we hooked him up to an EKG and … lo and behold … he was having a myocardial infarction.

According to the quality indicators at “HospitalCompare”, if a patient with a heart attack is going to receive thrombolytics (”clot busters”), the thrombolytics must be given within 30 minutes of the patient’s arrival at the hospital. If a health care provider takes longer than 30 minutes to administer thrombolytics to someone with a heart attack, the government considers that provider to be practicing bad medicine.

Now I’m faced with a choice:
A. Do I give clot busters to someone who sustained a significant head injury (and may be bleeding internally) so that I can look like a “good doctor” to Medicare and HospitalCompare.hhs.gov? If there is bleeding inside his brain, clot buster medications will make the bleeding worse and could kill him.
-OR-
B. Do I perform a CT scan on the patient to make sure that there is no bleeding inside his brain before I give the clot-buster medications? If I do the CT scan, there is no way that we’ll get the results and be able to give the patient thrombolytics within the 30 minute window.

If I choose “A,” the hospital stays in the upper echelon of facilities that meet HospitalCompare.hhs.gov’s guidelines. Doesn’t matter if the patient dies – according to Medicare, “We’re Number ONE!”

If I choose “B” I’m doing what is right for the patient, but our hospital will look bad and HospitalCompare.hhs.gov will plaster it all over the internet that our hospital doesn’t follow Medicare’s rigid and sometimes life-threatening guidelines.
I chose “B.”

According to HospitalCompare.hhs.gov, my decision made me a bad doctor…

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