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Aggressive Care: When Is It Better For Patients?

The recurring narrative among health reformers is that hospitals that provide more care raise health costs, but don’t necessarily improve quality. This has lead to a backlash against so-called “aggressive” hospitals and doctors, with upcoming financial penalties to match. But the situation, as always, appears to be more nuanced than that.

In her column in the New York Times, Dr. Pauline Chen looks at one subset of patients who actually may benefit from aggressive care: Those who suffer surgical complications. The study,

found no difference in the rate of complications for aggressive and nonaggressive hospitals. But when they looked at all the patients who had complications and examined their outcomes, the researchers found that regardless of the urgency of their operations, those patients who were cared for at more aggressive hospitals were significantly more likely to survive their complications than those who had their operations at less aggressive hospitals.

In addition, the investigators found that characteristics associated with intensity of care treated surgical complications better:

… a hospital’s failure or success in treating surgical complications correlated consistently with factors that also characterized intensity of care — general expenditures, intensive care unit use and the total days of hospitalization — they found that benefits of this more aggressive care extended well beyond the time of the operation.

I constantly remind readers of this blog that more medicine isn’t necessarily better. The counter-intuitive findings from the Dartmouth Atlas study have been instructive in convincing patients that they are, in many cases, overtreated. Read more »

*This blog post was originally published at*

How Good Is Your Doctor At Diagnosing You?

We’ve all been there. It often starts with some kind of recurring pain or dull ache. We don’t know what’s causing the pain or ache. During the light of day we tell ourselves that it’s nothing. But at 3:00am when the pain wakes you, worry sets in: “Maybe I have cancer or heart disease or some other life-ending ailment.” The next day you make an appointment to see your doctor.

So now you’re sitting in the exam room explaining this scenario to your doctor. Based on your previous experience, what’s the first thing your doctor would do?

A. Order a battery of tests and schedule a follow-up appointment.

B. Put you in a patient gown and conduct a thorough physical examination, including asking you detailed questions about your complaint before ordering any tests.

If you answered “A,” you have a lot of company. A recent post by Robert Centor, M.D., reminded me of yet another disturbing trend in the doctor-patient interaction. The post, entitled “Many doctors order tests rather than do a history and physical,” talks about how physicians today rely more on technology for diagnosing patients than their own “hands-on” diagnostic skills — a good patient history and physical exam, for example.

Prior to the technology revolution in medicine over the last 20 years, physician training taught doctors how to diagnose patients using with a comprehensive history and physical exam. More physicians today are practicing “test-centered medicine rather than patient-centered medicine.” Medical schools focus on teaching doctors to “click as many buttons on the computer order set as we possibly can in order to cover every life-threatening diagnosis.” The problem is that medicine is still an imperfect science, and technology is not a good substitute for an experienced, hands-on diagnostician. Read more »

*This blog post was originally published at Mind The Gap*

Concierge Medicine: The Cost Of Healthcare “Room Service” And Other Hospital Amenities

A per­spec­tive in [a recent] NEJM con­sid­ers the Emerg­ing Impor­tance of Patient Ameni­ties in Patient Care. The trend is that more hos­pi­tals lure patients with hotel-like ameni­ties: Room ser­vice, mag­nif­i­cent views, mas­sage ther­apy, fam­ily rooms and more. These ser­vices sound great, and by some mea­sures can serve an institution’s bot­tom line more effec­tively than spend­ing funds on top-notch spe­cial­ists or state-of-the-art equipment.

Think­ing back on the last time I vis­ited some­one at Sloan Kettering’s inpa­tient unit, and I mean­dered into the bright lounge on the 15th floor, stocked with books, games, videos and other signs of life, I thought how good it is for patients and their fam­i­lies to have a non-clinical area like this. The “extra” facil­ity is privately-funded, although it does take up a rel­a­tively small bit of valu­able New York City hos­pi­tal space (what might oth­er­wise be a research lab or a group of nice offices for physi­cians or, dare I say, social work­ers) seems wonderful.

If real healthcare isn’t an even-sum expense prob­lem, I see no issue with this kind of hos­pi­tal accou­trement. As for room ser­vice and order­ing oat­meal for break­fast instead of insti­tu­tional pan­cakes with a side of thaw­ing orange “juice,” chicken salad sand­wiches, fresh sal­ads or broiled salmon instead of receiv­ing glop on a tray, that’s poten­tially less waste­ful and, depend­ing on what you choose, health­ier. As for yoga and med­i­ta­tion ses­sions, there’s rarely harm and, maybe occa­sion­ally, good (i.e. value).

But what if those resources draw funds away from nec­es­sary med­i­cines, bet­ter soft­ware for safer CT scans and phar­ma­cies, and hir­ing more doc­tors, nurses or aides? (I’ve never been in a hos­pi­tal where the nurses weren’t short-staffed.) Read more »

*This blog post was originally published at Medical Lessons*

Minnesotans Get More Lower-Back MRIs: Why?

Kudos to Christopher Snowbeck and the St. Paul Pioneer Press for digging into new Medicare data to report that the state the newspaper serves is out of whack with the rest of the country in how many expensive MRI scans are done on Minnesotans’ bad backs.

Snowbeck artfully captures the predictable rationalization and defensive responses coming from locals who don’t like what the data suggest. Because what they suggest is overuse leading to overtreatment. So here’s one attempt a provider makes to deflect the data:

“The Medicare billing/claims data, which this report is generated from, would not capture conversations between a patient and provider that may have addressed alternative therapies for lower back pain,” said Robert Prevost, a spokesman for North Memorial Health Care. “It’s important to recognize the limitations of this data.”

No, data don’t capture conversations. But wouldn’t it be fascinating to be a fly on the wall during those many patient-physician encounters that led to an MRI to see what level of truly informed shared decision-making (if any) took place? Read more »

*This blog post was originally published at Gary Schwitzer's HealthNewsReview Blog*

High-Tech Scans Of Fruits And Vegetables?

Medical Pastiche blogger Peter Zavislak, whom I can always count on to point out the unusual and interesting sides of medicine, sent me to a website that has nothing but pictures and videos of food in an MRI scanner.
Here’s a series of images from their site of a cantaloupe as viewed from an MRI: 


I just find myself thinking that these MRI machines aren’t cheap to run and maintain. Doctors and nurses used to be able to get “freebies” by buddying up with the X-ray, CT or MRI technologist and running a scan for free.
Some hospitals allow their employees to test the machines after being set up or maintained to get images for testing purposes. I’m sure more than a technologist or radiologist or two have found incidentalomas from this practice. Read more »

*This blog post was originally published at The Happy Hospitalist*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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