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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.

Medicare’s Use Of Claims Data: Finding The Outliers

I have opposed Medicare’s use of claims data to evaluate the quality of medical care. Quality medical care is the goal that must be achieved. However, no one has described the measurement of quality medical care adequately.

Physicians recognize when other physicians are not performing quality medical care. Physicians recognize when another physician is just testing and performing procedures to increase revenue.

These over testing physicians are a small minority of physicians in practice.

Quality medical care is not about doing quarterly HbA1c’s on patients with Diabetes Mellitus. Quality medical care is about helping patients control their blood sugars so their HbA1c becomes normalized. It is about the clinical and financial results of treatment.

The clinical and financial results depend on both patients and physicians. Patients must be responsible for Read more »

*This blog post was originally published at Repairing the Healthcare System*

Gastroenterologists Need More Training To Be Competent With Colonoscopies

Much more practice is needed than gastroenterological professional societies currently recommend, concluded Mayo Clinic researchers in Rochester, Minn.

Current recommendations are that 140 procedures should be done before attempting to assess competency, but with no set recommendations on how to assess it, wrote the author of the research. But it takes an average of 275 procedures for a gastroenterology fellow to reach minimal cognitive and motor competency.

Now, the American Society for Gastrointestinal Endoscopy is rewriting its colonoscopy training guidelines to reflect the need for more procedures and emphasize the use of objective, measurable tests in assessing the competency of trainees. Read more »

*This blog post was originally published at ACP Internist*

How To Live Forever: Have A Dermatologist As Your Primary Care Physician?

Everyone has their own perspectives about life and death, often based on life experiences and their worldly views. Doctors are no different, except to say that doctors deal with life and death every day of their lives. For medical doctors, death perspectives are more likely to be defined by their disease specialty.
Here are a few examples of  death perspectives from the different medical specialties

If you’re a pulmonologist, nobody dies without first getting a bronchoscopy.If you’re a cardiologist, nobody dies without first getting a heart catheterization.If you’re a nephrologist, nobody dies without first getting a run of dialysis.If you’re an oncologist, nobody dies without first getting a course of chemotherapy.If you’re a neurologist, nobody dies without first getting an EEG and an MRI. If you’re a gastroenterologist, nobody dies without first getting a colonoscopy.If you’re a rheumatologist, nobody dies from lupus, because the answer is never lupus.  If you’re an infectious disease doctor, nobody dies without first getting a course of doxycycline.If you’re a family practice physician, nobody dies without getting a consult.If you’re an internist, nobody dies without first admitting the patient to the hospitalist.If you’re a dermatologist, nobody dies. Period.

What’s the moral of the story?  If you want to live forever,  get a dermatologist as your primary care physician.

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

Why Doctors Should Be Less Like Chuck Yeager And More Like Captain Sullenberger

A recent medical error of a wrong-site surgery that occurred in one of the country’s best hospitals, Massachusetts General, reminded me why doctors need to be less like Chuck Yeager and more like Captain Sullenberger.

Growing up, I always wanted to be a fighter pilot, years before the movie “Top Gun” became a part of the American lexicon. My hero was World War II pilot Chuck Yeager, who later became one of the country’s premier test pilots flying experimental jet and rocket propelled planes in a time when they were dangerous, unpredictable, and unreliable.

Much like the astronauts in the movie “The Right Stuff,” Yeager and his colleagues literally flew by the seat of their pants, made it up as they went along, and never really knew if their maiden flight in a new aircraft might be their last. They were cowboys in the sky wrangling and taming the heavens.

Fast forward to January 2009, when shortly after takeoff, a one-in-a-million chance, a double-bird strike completely disabled a US Airways jetliner. Captain Chesley Sullenberger, with the help of his co-pilot Jeff Skiles, ditches the aircraft in the Hudson River in under four minutes even as the nation surely expected a tragedy. But not on that day. Not with that pilot. Read more »

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

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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