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Latest Posts

Do We Really Need Another Branch Of Government To Enforce Medical Informed Consent?

Health Leaders Media recently published an article about “the latest idea in healthcare: the informed shared medical decision.”  While this “latest idea” is actually as old as the Hippocratic Oath, the notion that we need to create an extra layer of bureaucracy to enforce it is even more ridiculous. The author argues that physicians and surgeons are recommending too many procedures for their patients, without offering them full disclosure about their non-procedural options. This trend can be easily solved, she says, by blocking patient access to surgical consultants:

“The surgeon isn’t part of the process. Instead, patients would learn from experts—perhaps hired by the health system or the payers—whether they meet indications for the procedure or whether there are feasible alternatives.”

So surgeons familiar with the nuances of an individual’s case, and who perform the procedure themselves, are not to be consulted during the risk/benefit analysis phase of a “shared” decision. Instead, the “real experts” – people hired by insurance companies or the government – should provide information to the patient.

I understand that surgeons and interventionalists have potential financial incentives to perform procedures, but in my experience the fear of complications, poor outcomes, or patient harm is enough to prevent most doctors from performing unnecessary invasive therapies. Not to mention that many of us actually want to do the right thing, and have more than enough patients who clearly qualify for procedures than to try to pressure those who don’t need them into having them done.

And if you think that “experts hired by a health insurance company or government agency” will be more objective in their recommendations, then you’re seriously out of touch. Incentives to block and deny treatments for enhanced profit margins – or to curtail government spending – are stronger than a surgeons’ need to line her pockets. When you take the human element out of shared decision-making, then you lose accountability – people become numbers, and procedures are a cost center. Patients should have the right to look their provider in the eye and receive an explanation as to what their options are, and the risks and benefits of each choice.

I believe in a ground up, not a top down, approach to reducing unnecessary testing and treatment. Physicians and their professional organizations should be actively involved in promoting evidence-based practices that benefit patients and engage them in informed decision making. Such organizations already exist, and I’d like to see their role expand.

The last thing we need is another bureaucratic layer inserted in the physician-patient relationship. Let’s hold each other accountable for doing the right thing, and let the insurance company and government “experts” take on more meaningful jobs in clinical care giving.

Oncologist Considers Heat-Based Cancer Treatment

There’s so much weird and exciting cancer news this week, it’s hard to keep up!

Double-kudos to Andrew Pollack on his front-page and careful coverage in the New York Times of the hyperthermic intraperitoneal chemotherapy (Hipec) technique that’s being used at some name-brand health care facilities to treat colon cancer.

First, he spares no detail in the Times describing the seemingly primitive, crude method:

….For hours on a recent morning at the University of California, San Diego, Dr. Andrew Lowy painstakingly performed the therapy on a patient.

After slicing the man’s belly wide open, Read more »

*This blog post was originally published at Medical Lessons*

Medical Journalism And The Patient’s Voice In The Media

Yesterday’s post was not really about Avastin, but about medical journalism and how patients’ voices are handled by the media.

L. Husten, writing on a Forbes blog, cried that the press fawned, inappropriately, over patients’ words at the FDA hearing last week, and that led him to wonder why and if journalists should pay attention to what people with illness have to say, even if their words go against the prevailing medical wisdom.

There’s a fair amount of controversy on this. For sake of better discussion in the future, I think it best to break it up into 3 distinct but inter-related issues:

1. About health care journalism and patients’ voices:

A general problem I perceive (and part of why I started blogging) is how traditional medical journalists use patients’ stories to make a point. What some of my journalism professors tried to teach  me, and most editors I’ve dealt with clearly want, is for the reporter to find a person with an illness, as a lead,  and then tell about the relevant news, and provide some expert commentary – with at least one person speaking on each “side” of the issue, of course – and then end the story with some bit about the patient and the future.

I argue that this form of medical journalism Read more »

*This blog post was originally published at Medical Lessons*

Bend The Cost Curve In Cancer Care: Reduce Excessive Surveillance Testing

This is the second in a series of posts on Bending the Cost Curve in Cancer Care. We should consider the proposal, published in the NEJM, gradually over the course of this summer, starting with “suggested changes in oncologists’ behavior,” #1:

1. Target surveillance testing or imaging to situations in which a benefit has been shown. This point concerns the costs of doctors routinely ordering CTs, MRIs and other imaging exams, besides blood tests, for patients who’ve completed a course of cancer treatment and are thought to be in remission.

The NEJM authors consider that after a cancer diagnosis many patients, understandably, seek reassurance that any recurrence will be detected early, if it happens. Doctors, for their part, may not fully appreciate the lack of benefit of detecting a liver met when it’s 2 cm rather than, say, just 1 cm in size. What’s more, physicians may have a conflict of interest, if they earn ancillary income by ordering lab and imaging tests.

My take:

It’s clear that some and possibly most cancer patients get too many and too frequent post-treatment surveillance tests. Read more »

*This blog post was originally published at Medical Lessons*

How To Ensure Productive Interactions Between Clinicians And Patients

I sat in a dingy pharmacy near the Seattle airport over the holidays, waiting for an emergency prescription.  For over two hours I watched a slow-moving line of people sign a book, pay and receive their prescription(s). The cashier told each customer picking up more than one prescription or a child’s prescription to wait on the side.  In minutes, the harried white-haired pharmacist came over to ask the person if they were familiar with these medications, described how to take them, identified the side effects to look out for and demonstrated the size of a teaspoon for pediatric medications.  Then he asked the person to repeat back – often in broken, heavily accented English – what he or she had heard and patiently went over the parts they didn’t understand.

I was impressed. This is what every pharmacy should be like – except, of course, for the dinginess, the creeping line and the fact that it was so crowded I could overhear these conversations.  Maybe if we got federal legislation enacted requiring pharmacists to offer counseling with each prescription filled, this kind of attention would be the norm, adherence to medication regimens would improve and drug-related injuries would be reduced.

Wait a minute.  Someone already had that good idea.  It was Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Latest Interviews

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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How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

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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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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