January 26th, 2009 by Dr. Val Jones in Uncategorized
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When I was invited to join a blog conference at the Consumers Union headquarters in Yonkers, I had no idea what to expect. It hadn’t dawned on me that the company is as large as it is – employing 630 people (most of whom work out of the warehouse-sized building in NY) with a 60 million dollar/year budget. The facility itself is a beehive of product testing labs – with rooms devoted to the analysis of product performance for everything from washing machines to baby strollers.
And what were health bloggers doing in the midst of this? Apparently Consumer Reports is dipping their toe into the health ratings game, and they wisely decided to ask providers what they made of that. I explained my experience with the lack of consumer incentives to rate doctors – and offered a cautionary tale of a failed rating database at my previous company. Others suggested that quality ratings are impossible to quantify without consistent data reporting, and that care is provided to most patients by teams of providers, not one single physician, so ratings might not mesh well with outcomes anyway.
We had a productive discussion with familiar faces and old friends (Jan Gurley, Micheal Breus, Edwin Leap, Dr. Rob, Amy Tenderich, Scott Hensley, Julie Deardorff, Alvaro Fernandez, Jennifer Huget, Wendy Lawson, Craig Newmark, Gary Schwitzer, and others) but my favorite part of the program involved cookie taste- testing.
We bloggers all filed in to the sensory testing lab and were asked to sample some commercial chocolate chip cookies. Each of us had our own little plastic container with two cookies inside, and we were instructed to taste and describe them in as detailed a manner as possible. I offered “chalky” as my adjective of choice, and Scott Hensley (of the Wall Street Journal Health Blog) seconded my notion as another blogger added “chemically.”
There was general consensus that we didn’t like the cookies – and we began inquiring as to their brand name. The Consumer Reports lab director dutifully declined to disclose the manufacturer’s name, at which point Scott Hensley reached into a nearby garbage can and produced an empty cookie package. He held the wrapper aloft and asked with gleeful sarcasm: “Might it be this brand here?”
We all burst into laughter as a triumphant Hensley proved his investigative reporting skills in the midst of us. It was one of those surreal moments that you never forget.
But on a more serious note, I was struck by the scientific approach that Consumers Union takes in its product testing. It struck a chord with me since I worry about the evidence (or lack thereof) behind certain medical practices and treatments. The Internet seems to be teaming with subjectivity rather than tested and true information. How are consumers to know what’s real anymore?
I certainly hope that companies like Consumers Union can weather the financial storms and continue to empower people with carefully tested, controlled, and unbiased information. Without them we’re left with a bunch of anecodotes in a sea of opinion. Perhaps physicians and health scientists have more in common with Consumers Union than we know? I for one am convinced that our common interests go even deeper than chocolate chip cookies.
January 24th, 2009 by Dr. Val Jones in Book Reviews
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Laurie Edwards has an extremely rare disorder called primary ciliary dyskinesia (PCD). The condition causes similar signs and symptoms to cystic fibrosis (CF), including chronic lung infections and difficulty breathing. In her recent book, Life Disrupted: Getting Real About Chronic Illness In Your Twenties And Thirties, Laurie invites readers to experience her life as a chronically ill young woman. She spares no gory details:
I had to wear the probe for forty-eight hours to see if irregularities in my GI tract were contributing to my breathing problems. It was an awkward contraption, and just as I finished speaking, I sneezed. Because of the tubes, I couldn’t control it well and a bloody mess spewed out of my nose and onto my shirt. I looked down at the mess and up at John.
‘Sexy, huh?’ I asked, completely mortified.
But beyond the raw realities of her illness (including the regular disruption in her education, her unfulfilled longings to “fit in,” and her lack of control of her circumstances), is the amazing story of the people who love her. Life Disrupted‘s ironic subtext is the unshakable support of her family and friends.
From her earliest first moments at home, Laurie’s brother “spent hours standing guard at her bassinet, as if to reassure her mother nothing would happen to her.” As she grew older, her brother continued his protective commitment, promising to always be ready to help her in any time of need. Laurie’s parents had a strong and loving marriage, and their patience and kindness were a constant source of security and comfort.
Laurie’s husband shows incredible stoicism and endurance – undeterred by her diagnosis (which she revealed to him unwittingly on their first date), he learns how to give her chest physical therapy by week three of their relationship, and remains calm during a dangerous near-suffocation episode.
He was perfect. He did not get flustered, did not panic, just got me home as quickly as possible, unlocked my door, and ran to set up the nebulizer. He clapped me while I positioned myself with the nebulizer mask and tubing, trying to manually break up the thick mucus that cut off my air supply.
My favorite part of Life Disrupted is its humor. Laurie does an admirable job of capturing the amusing banter that she and her friends used to lighten the mood:
My friends and I refer to my nebulizer and oxygen face mask in the hospital as the “Super Bong.”
And my favorite sentence of the book is this one:
It was a container of honey mustard salad dressing that turned out to be my Waterloo, the moment of my crushing, flabbergasting defeat.
Laurie’s life – disrupted by chronic illness – is charming, vibrant, and rich in affection. The disruption itself is perhaps diminished by the connectedness of her family and friends – a healthy emotional backdrop to the physical illness at center stage. In the end, Life Disrupted offers compelling evidence that love really can conquer all.
January 22nd, 2009 by Dr. Val Jones in Medblogger Shout Outs
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My friend and fellow medblogger Peggy Polaneczky, MD had this to say after returning from a medical conference in Salzburg:
We had lots of conversations about healthcare in our respective countries. And all I can say is, despite all the issues we have in the United States, I wouldn’t want to be practicing medicine anywhere else but here. Not when I hear tale of docs whose only way of surviving financially is to take tips from patients who pay to squeeze into the surgical schedule ahead of the cue. Or of abdominal emergencies handled in hospitals that don’t have a CT scanner. And not a single fellow has a microscope in their office, forcing them to rely on gram stain only for management of vaginitis. (A poor substitute for an in office wet prep in my opinion.)
Most of these docs would give their eye teeth to spend some time learning medicine in the United Sates, be it something as simple as an observership or as complex as a second residency. Unfortunately, visa regulations in their countries and ours make this extremely difficult. But all of them will be offered observerships in Vienna and in Germany at the Institute’s expense.
January 21st, 2009 by Dr. Val Jones in Primary Care Wednesdays
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By Alan Dappen, M.D.
“Doc, you’re the best! You saved my life, and my wife’s. You delivered my kids and brought them through sickness — time and again. I trust you, and can confide in you … Hey, wait a minute … Are you still a Preferred Provider?”
This is a statement I heard all too often as a primary care doctor beholden to third-party providers. When a long-time patient asked this question, I felt like the mythological Damocles, who precariously sat beneath a sword suspended by a horse hair, for if I answered “No” to that question of “Are you a Preferred Provider” the sword would fall, swiftly.
No matter skill, knowledge, talent, caring, quality, experience, price or level of trust of their current primary care practitioner, 90-95% of patients who ask “Are you my preferred provider?” paradoxically will exit one primary care provider’s office to entrust the decisions of their day-to-day health care to another physician picked by their insurance company, even though this new doctor may be a stranger who signs a contract to do the job for less money.
For decades now patients have been led, like lemmings, by the belief that the vast majority of healthcare is virtually free because they have health insurance usually wholly and partially funded by someone else, like their employers of the government. Furthermore, patients trust that the providers of this health insurance know what is best for their care.
Because someone else is footing the bill, we as patients have absolved ourselves of the responsibilities associated with finding and consuming good care. Instead, the hope of getting what appears to be virtually free health care trumps all other considerations of care, whether it is quality, level of expertise, convenience or accessibility. Few of us are immune to wanting to get something for less, or better yet, something for nothing. This behavior leads to moral hazards, which are most easily explained by the WIFM (“What’s in it for me”) concept, and best exemplified by the way we eat at a buffet, drink at an open bar, or most recently by how the banks flocked to the sub-prime market to make easy, big money.
In health care, these moral hazards mean patients do not hold themselves accountable for finding the quality of care they desire at a price that makes sense. Instead, patients often rush for more health care believing that more care is better care; or to specialists because this means more competent care; or to more tests because this translates to more comprehensive results; and finally to more drugs and more treatments because these mean a longer, happier life. And patients do so because they believe their care is “free.”
Most patients are loathe to believe the numerous studies contradicting many of these beliefs. Due to the set up of the current “free” care healthcare system, patients are shielded from the actual costs of care, so they do not carefully consider these costs when assessing care. Take, for example, that a new chemotherapy drug for colon cancer cost $40,000, and yet only adds an average 1.5 months onto a patient’s life. Or that the newest brand name antidepressant costs 6 times more than its older, generic cousin (Prozac), with no evidence that it works any better. And finally, consider this example: a 70 year-old man with severe, irreversible chronic end-stage heart and renal failure, who has been bed-ridden for 3 months with numerous deep bed sores, and whose family demands “keep him alive no matter the cost.”
Unfortunately, the WIFM game doesn’t end with the patient. Imagine the beauty of running a business when all your customers say, “Don’t worry, just send the bill to Mom (the employer) and Dad (the government) and they’ll pick up the tab.” It is not rocket science to understand how this led physicians to a business model that guaranteed customers as long as they played by the providers’ rules; nor to understand how drug companies produce more and more “me too” drugs that offer no advantages over generic precursors but cost 6 times more; nor to see primary care physicians moving to specialization, with little difference in training compared to primary care while doubling or tripling fees; nor insurance companies keeping 30-40% of all collected money for “administration, policing, and profits,” and their executive team pocketing exorbitant rewards, like the United Health Care CEO who amassed almost $2 billion in just a few years. How dare he?!
This then is the systemic toxic effects of our health care system. The moral hazard of free healthcare binds us into one big dysfunctional family. Whatever happens, let’s make sure someone else is paying for care.
Here’s the rub: insurance has a social value for protection against large or chronic, recurring costs to help ensure your financial well-being. Primary care, on the other hand, is something all of us need, on average 1-2 hours a year and a can cost the patient as little as $300. What minimal cost to pay for staying healthy today, building for a healthy tomorrow, and ideally decreasing our need for more expensive healthcare later on. Yet few are willing to pay only a little bit today for their day-to-day care – no matter its level of quality, accessibility or convenience, unless it is “free.” So, in a world of moral hazards, what is going to happen to typical primary care?
Stay tuned and we’ll review the dirty little secrets primary care plays to survive and why it really does matter to you.
Until next time, I remain yours in primary care,
Alan Dappen, M.D.
When I was invited to join a blog conference at the Consumers Union headquarters in Yonkers, I had no idea what to expect. It hadn’t dawned on me that the company is as large as it is – employing 630 people (most of whom work out of the warehouse-sized building in NY) with a 60 million dollar/year budget. The facility itself is a beehive of product testing labs – with rooms devoted to the analysis of product performance for everything from washing machines to baby strollers.
