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Why Doctors Are Better Than Google

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“One major responsibility of an expert is to know what to ignore.”

Scott Haig, MD

Health information is more plentiful and accessible to patients than ever before. As a physician I am thrilled that people are empowered with knowledge to take control of their health, but I am also sincerely worried about the “misses:” misinformation, misconceptions, misdiagnoses and mistakes.

The great sculptor Michelangelo believed that every piece of marble was a beautiful statue just waiting for the artist to remove the parts that didn’t belong. I believe that this principle applies to health information – the utility of the information is directly proportional to the reader’s ability to ignore the parts that are irrelevant or incorrect. Google cannot remove the irrelevant, because it can’t evaluate the science behind various claims, appreciate the nuances of an individual’s life circumstances, or confirm a diagnosis. No, as powerful and wonderful as search engines are, they are mere marble. The master sculptors in health information are physicians – trained for at least a decade in the art of analyzing data, appreciating the connectedness of various symptoms and body systems, and focused on chipping away at the irrelevant to uncover personalized solutions and cures – they are the artists whose experience and insight can make the difference between life or death.

Are sculptors flawed? Sure. Are some better than others. Yes. But the bottom line is that information in the hands of a person who can apply it in an intelligent, personalized, and relevant way is our best shot at good, quality healthcare. There is an art to medicine, and the trick is to know what to ignore. Find a good sculptor and stick with him/her so that you can live your very best and avoid the “misses!”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Are Cash-Only Medical Practices The Wave Of The Future?

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MedPage Today issued a special report on a rising trend: cash-only medical practices. I guess I’m ahead of the curve, since I’ve been seeing a cash-only primary care physician for 2 years now – and I love it.

Dr. Alan Dappen is available to his patients 24 hours a day, 7 days a week, by phone, email and in person. Visits may be scheduled on the same day if needed, prescriptions may be refilled any time without an office visit, he makes house calls, and all records are kept private and digital on a hard drive in his office.

How much would it cost to have the luxury of a personal physician on-call for your every whim?

Would you believe only about $300/year?

What’s Dr. Dappen’s secret to success? He accepts no insurance, keeps his overhead low, offers full price transparency, has physician extenders who work with him, and charges people for his time, not for a complex menu of tests and procedures.

“I believe in doing what is necessary and not doing what is not necessary. The healthcare system is broken because it has perverse incentives, complicated reimbursement strategies, and cuts the patient out of the billing process. When patients don’t care what something costs, and believe that everything should be free, doctors will charge as much as they can. Third party payers use medical records to deny coverage to patients, collectively bargain for lower reimbursement, and set arbitrary fees that reward tests and procedures. This creates a bizarre positive feedback loop that results in a feeding frenzy of billing and unnecessary charges, tests, and procedures. Unlike any other sector, more competition actually drives up costs.”

After building a successful traditional family medicine practice in Fairfax Virginia, Dr. Dappen felt morally compelled to cease accepting insurance so that he could be free to practice good medicine without having to figure out how to get paid for it. He noticed that at least 50% of office visits were not necessary – and issues could be handled by phone in those cases. Phone interviews, of course, were not reimbursable by insurance.

“The physical exam is a straw man for reimbursement. Doctors require people to appear in person at their offices so that they can bill for the time spent caring for them. But for longstanding adult patients, the physical exam rarely changes medical management of their condition. It simply allows physicians to be reimbursed for their time. Cutting the middle man (health insurance) out of the equation allows me to give patients what they need without wasting their time in unnecessary in-person visits. This also frees up my schedule so that I can spend more time with those who really do need an in-person visit.”

Health insurance is certainly necessary to guard against financially catastrophic illness. And the poor need a safety net beyond what Dr. Dappen can provide. But for routine care, “concierge medicine” can make healthcare affordable to the middle class, and reduces costs by at least 50% while dramatically increasing convenience. For the right patient, this is a welcome relief from having to wait to be seen by in-network providers or from being billed non-preferred rates as an uninsured individual. I applaud Dr. Dappen for his efforts in healthcare reform, and look forward to a movement where costs are driven down by putting patients back in the payer seat.

School Gives Birth Control Pills To 11 Year Old Girls

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You might have seen the recent news about the middle school in Maine – King Middle School, in the Portland school district – that is planning to provide birth control to pre-teens, without requiring explicit parental consent. School officials argue that this will help to prevent pre-teen pregnancies, and estimate that at least 5 out of 135 of their 11- to 13-year-old female students are sexually active already.

While I absolutely sympathize with the desire to avoid pre-teen pregnancies, and I do understand that there is a reality here that some very young children will become sexually active at the tender age of 11, I personally do not support giving pre-pubescent girls hormone-altering tablets. We do not have good studies demonstrating the safety of such therapies in children, and until we do it’s just not medically sound to be offering this treatment. (For example, we don’t know what extra estrogen does to early breast buds, or whether there’s an increased risk for developing breast cancer later on.)

I also think that 11 year olds are not physically and emotionally prepared for sexual intimacy – and the prematurity of this event could be quite harmful for their psyche. We know that 11- and 12-year-old brains are not fully developed to think the way adults do, so there’s really no telling what impact it could have or what long term psychological effects might result.

Apparently sex before the age of 14 is illegal in Maine, so (although there’s no doubt that it may happen prior to that age) it seems that the state’s legal system is not in step with their school system, and that needs to be looked at. It is inconsistent to claim that an activity is illegal for children and then enable it with tax dollars.

I suppose that education about the use of condoms and access to them (without aggressive promotion of them) may be acceptable at this age. After all, condoms can prevent STDs and don’t have medical effects on the body as a whole. But my plea is that parents take the lead here – and educate your children about the risks of STDs, pregnancy, and the emotional damage that premature sex can have on a young person. Advocate for abstinence as a first choice, explain that condoms are non-negotiable, and try to help them turn their focus away from sex and towards more age-appropriate endeavors.

A new Dove advertising campaign asks parents to talk to their kids before the beauty industry does, and I think the same goes for sex and the media. Today’s parent must launch a preemptive strike against the over-sexualization of children, or risk having their 11 year olds taking estrogen patches from a school nurse without their consent.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What Does Labor Day Have To Do With Doctors?

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Labor Day was founded in the late 1800’s as a way to thank
American workers (as Peter J. McGuire, a cofounder of the American Federation
of Labor put it): “who from rude nature have delved and carved all the grandeur
we behold.”  There is some debate
about who originated the concept of the holiday, but one truth remains:

“All other
holidays are in a more or less degree connected with conflicts and battles of
man’s prowess over man, of strife and discord for greed and power, of glories
achieved by one nation over another. Labor Day…is devoted to no man, living
or dead, to no sect, race, or nation…  It
constitutes a yearly national tribute to the contributions workers have made to
the strength, prosperity, and well-being of our country.”

Resident physicians are on my mind with Labor Day
approaching. I know that they are toiling away in hospitals across the nation,
and many of them do not get to take Labor Day off for vacation.  Physicians work for 3-7 years after
graduating from medical school, and are paid (on average) about the equivalent
of a home health aide or a medical secretary but work about twice the hours
during residency.  In fact, if you calculate
out the salary by the hours they work, resident physicians are paid about $9
-$10/hour which is roughly $1.50 more than minimum wage.

Not surprisingly, resident physicians have joined unions to
lobby for more reasonable wages and caps on the number of hours they must work
per week.  The national cap is now at 80
hours per week – about 20 hours more than a truck driver is allowed to work
(for “safety reasons”).  Research from Harvard
suggests that errors made by overworked residents increase by 700% when they
have worked more than 24 hours in a row.

Residents from the University of New Mexico, for example, received wages in the lowest 1% for resident physicians in their region, and
were denied a salary increase until they recently joined forces with CIR (the Committee of Interns and Residents) to
negotiate more reasonable salaries and working conditions.  The New
Mexico contract adds one more CIR chapter to the more
than 70 hospitals — each with multiple residency programs — that are part of
CIR.

Founded in 1957 to improve patient care and resident working
conditions, CIR has remained true to those two goals throughout the decades. In
1975, CIR won an end to every other night on-call in New
York City, and created the first-ever Patient Care Fund in Los Angeles, where
residents could purchase equipment or create innovative programs to help
patients. Campaigns to prevent needle stick accidents by moving to safer needles,
or needle-less equipment, have also improved working conditions for residents.

CIR has been on the forefront of safe and humane work hours
for residents, helping to win the 80 hour regulations in New York State
in 1989, which became the foundation for the 2003 national guidelines. But
evidence shows that this is still too many hours, and so the advocacy around
hours continues unabated.

So please have safe travels on your Labor Day weekend – we
wouldn’t want you to wind up at a hospital where the residents work more than
24 hours in a row for ~$9/hour.  Resident
physicians are one group of laborers who don’t have much to celebrate yet this
Labor Day.  But with CIR’s help, next
year might be a little brighter.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Facing Our Own Mortality: Richard Dawkins and Alternative Medicine

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On the recommendation of several members of the blogosphere, I’ve been watching a new British TV Series called “The Enemies of Reason” hosted by Richard Dawkins, a noted atheist and evolutionary biologist at Oxford.  The series offers a skeptical review of the claims of alternative medicine practitioners, strung together with Michael Moore-like skill, and designed to showcase the fringiest believers as they concoct wild, pseudoscientific explanations for the mechanism of action of their therapies.  It is entertaining and whimsical – though Dawkins himself appears dogmatic and cold as he ultimately builds a case for science as a religion.

Although I agree with Dawkins on many points, I think his approach is somewhat superficial and unnecessarily adversarial.  Instead of unmasking kookiness and labeling people as “enemies of reason,” I think it would be more interesting to ask: why are people seeking out pseudoscience?  What is the deeper need that scientific medicine is not satisfying?  Why are billions spent on alternative therapies?  (Please note that the “alternative therapies” that Dawkins evaluates include things like quantum homeopathy, magnetic healing, angelic guidance, and other treatments that don’t have evidence-based underpinnings.)

I think that at the very heart of the matter is that we humans want to feel in control.  For millennia we’ve been conjuring up bizarre theories in order to believe that we can influence our destinies and our health.  Just take for example the elaborate Egyptian religious myths (health was controlled by one’s ka which required regular food and drink offerings – not to mention all the elaborate embalming rituals to influence a good afterlife).  All of these rituals provided the Egyptians with a sense of control over their lives, deaths, and reincarnations.  I’m not entirely sure that we humans today are much different in our desire to control our lives.  We just manifest it in other ways.

Ironically, science feeds pseudoscience – the more we know, the more definitive we can be about a disease or its prognosis – and the greater the desire to buck against that.  And so as we advance in medical understanding, it is not surprising that there is renewed interest in magic as a means of influencing our clinical course as the inalterable progression becomes clearer and clearer.  Add to that the fact that the physician-patient relationship has been undermined by a series of unfortunate historical circumstances (the rise of health insurance middle men, decreasing reimbursements, administrative red tape, etc.) and you have a group of dissatisfied patients with chronic diseases that have predictable complications – all seeking alternative outcomes at the hands of any compassionate person who promises to give them some control back.  Of course, our “quick fix” culture also gives rise to a preference for simple solutions, rather than complex (though effective) ones.  Is there any wonder that snake oil has emerged as a major player in this climate?

Dawkins makes the convincing argument that certain alternative medicine practices rely entirely upon the placebo effect.  If this is the case, practitioners of these therapies cannot admit that their remedies are placebos – in so doing they would undermine their potential effects.  Therefore, one cannot expect a rational response from them when confronted with evidence that their strategies do not work or are implausible.  For the remedies to have a perceived effect, they only need to be believed in by the recipient.  The millions of dollars spent by the National Health Service and National Institutes of Health attempting to uncover the mechanism of action of implausible therapies (such as homeopathy) will not influence the millions of faithful believers who turn to such practices for their health.  I suppose that once the placebo effect has been scientifically proven, only the skeptics will be convinced by the data.

In the end however, Dawkins’ “war” is not between the evidence based medicine camp and the placebo based medicine group, it’s really an internal battle that each of us faces about our own mortality.  The process of coming to terms with health and disease is uniquely personal – some want to be (as Dawkins puts it) coddled, others want the cold hard facts.  As for me, all I want is for patients to be able to make informed decisions, not to be misled about therapeutic safety or efficacy, and not to be guided away from known effective treatments and towards known ineffective treatments.  I suspect that this is what most people want as well.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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