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Physicians Are Biased About Healthcare Reform

July 28th, 2009 by Shadowfax in Better Health Network, Health Policy

Tags: Bias, Conflicts of Interest, Costs, Emergency Medicine, Healthcare reform, Making Money, Obama, Physicians, Primary Care

From the department of “Credit where it’s due,” in the comments of my post on the Lewin Group, Nurse K pointed out the following:

Come on Shadowfax, you’re blogging about this stuff and you stand to make A TON of money if it goes through…for awhile…until insurance companies decrease your compensation since you’re making more per patient. I know you mentioned this before in like a comment or something, but ER docs stand to benefit (temporarily) probably more than anyone else. HUGE bias on your part.

Much as I (really, really) hate to admit it, she’s absolutely right.  In fact, I’ll go one further: I first got interested in this part of medicine policy because I was mad that I was seeing all these uninsured patients and wasn’t getting paid a thing for my efforts.  I started keeping track of the number of uninsured I saw every day, just as a pet obsession.  It was a sobering number.  After that I started getting a little perspective, talking to patients and seeing their bigger picture, understanding why they were uninsured, learning the particular challenges they faced getting health care, etc.   For me, this cause became something beyond the personal a long time ago and became a moral imperative.

But K is right to note the potential for bias, and it’s fair for me to acknowledge it.  I hope that my integrity on this point is evident.  The fact that I argued in the New York Times for an increase in primary care compensation, with an attendant decrease in the compensation of specialists, including Emergency Medicine, should speak well for my ability to see beyond personal self-interest. (God knows it didn’t make me popular in EM circles!)

This is something which struck me yesterday, reading the med blogs reaction to Obama’s presser.  Quite a few docs mounted their high horse and with great indignation denounced this:

Doctors are forced to make decisions based on a fee payment schedule that’s out there. So they’re looking… if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, “I’d make a lot more money if I took this kids tonsils out.” Now that might be the right thing to do, but I’d rather have that doctor making those decisions based on whether you need your kids tonsils out…

Now it’s a clumsy clinical scenario written by someone who has no clue about medicine.  But it’s a damned fair point.   Bias comes writ large, as in the Walter Reed orthopod who pocket $850K and falsified his research to benefit Medtronic, and it comes writ small, as in the ER doc who sees a small lac and has to decide whether to use a band-aid or a stitch, knowing that the stitches will pay 10x more.  It comes with the cardiologist who has to decide whether to take a low-grade troponin leak to the cath lab.  It comes with the surgeon seeing a patient with unusual abdominal pain and a slightly enlarged appendix on CT (you can observe or just take out the appy; guess which pays more).

Whether there’s a “fix” for that in the current reforms is debatable.  It harms our standing, however, to deny the possible existence of bias and to claim a moral purity that, as a profession, is not justified.  I think and hope that most of us in these ambiguous situations are able to come to the right decision for the patient the vast majority of the time regardless of our economic interests.  The best way to remain credible is to acknowledge the mere potential for bias and move on and debate the salient point.  Making counter-factual arguments that biases do not exist or that we physicians are too awesomely altruistic to ever be influenced by them does nobody any good.

*This blog post was originally published at Movin' Meat*

The Newest Eating Disorder: Orthorexia Nervosa

July 27th, 2009 by Nancy Brown, Ph.D. in Better Health Network

Tags: Addiction Medicine, Diet and Nutrition, eating disorder, Neurosis, Orthorexia Nervosa, Pediatrics, teens

Orthorexia is a term coined by Dr. Steven Bratman. “Ortho” simply means straight or correct, while “orexia” refers to appetite. Orthorexia nervosa refers to a nervous obsession with eating proper foods. While anorexia nervosa is an obsession with the quantity, orthorexia is an obsession with the quality of the food consumed.

Given how heavy people seem to be getting in our country, focusing on health should not be a bad thing. However, while it is normal for people to change what they eat to improve their health, treat an illness, or lose weight, orthorectics may take the concern too far. While it is normal for people switching diets to be concerned with what types of food they are eating, this concern should quickly decrease, as the diet becomes normal. Orthorexia, in contrast, is when a person is consumed with what types of food they are allowed to eat and feel badly about their selves if they fail to stick with their regimen.

People suffering with this obsession about what they eat may find themselves:
• Spending more than three hours a day thinking about healthy food.
• Planning tomorrow’s menu today.
• Feeling virtuous about what they eat, but not enjoying it much.
• Continually limiting the number of foods they eat.
• Experiencing a reduced quality of life or social isolation (because their diet makes it difficult for them to eat anywhere but at home).
• Feeling critical of others who do not eat as well they do.
• Skipping foods they once enjoyed to eat the “right’ foods.
• Feeling guilt or self-loathing when they stray from their diet.
• Feeling in “total” control when they eat the correct diet.

Often orthorectics will “punish” themselves by doing a penance of some sort, if this “fall from grace” does occur. While orthorexia nervosa isn’t yet a formal medical condition, many professionals do feel that it does explain an important health phenomenon. If you or someone you know suffers from something that sounds or feels like this description of orthorexia nervosa, you should go visit either a nutritionist or doctor.

References
1) Bratman, Steve. “Health Food Junkie–Orthorexia Nervosa, the New Eating Disorder.” 1997.
2) Billings, Tom. “Clarifying Orthorexia: Obsession with Dietary Purity as an Eating Disorder.” 1997
3) Davis, Jeanie. “Orthorexia: Good Diets Gone Bad.” November, 2000.
4) Fugh-Berman, Adriane. “Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession with Healthful Eating–A Book Review.” May 2001.
5) Dennis, Tamie. “Booster Shots.” Los Angeles Times, 7/09

Photo credit: Meg and Rahul

This post, The Newest Eating Disorder: Orthorexia Nervosa, was originally published on Healthine.com by Nancy Brown, Ph.D..

Blood Under The Nail – What To Do

July 27th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips

Tags: blood under the nail, Dermatology, hiking, ice, make a hole, Primary Care, relieve pressure, subungual hematoma

The following is a message that I received from a reader:

“Professor Auerbach – I am an avid reader of your blog ‘Medicine for the Outdoors.’ Your two posts about foot blisters are really interesting. In my hiking experience there is another foot related issue, that is the subungual hematoma in the toenail. I think it could be an interesting subject in one of your blog posts. Thank you very much for the attention.”

Well, it just so happens that I have been a sufferer myself, so I’m happy to write a bit about this. Subungual hematoma refers to blood under a toenail or fingernail. In the fingers, this usually occurs from a blow or pinch, such as catching a finger in a door or striking it with a hammer. In the foot, it is commonly caused by repetitive blows in a confined space, such as hiking in a boot with a toe-box that is too small and/or too stiff. The photo above is my foot after a 10 mile hike over rocky terrain in hiking shoes that didn’t fit quite right. They were broken in, but they weren’t sufficiently flexible for that type of hike. A couple of hours in, I knew I was in trouble because of the pain, but there was no turning back. No surprise, when I took off my sock, I saw the blue color and knew that eventually that particular toenail was a goner.

What can be done about this condition? When it first happens, applying an ice pack might relieve the pain. Certainly, you should trade out the poorly fitted shoes for ones that provide greater room and comfort. If possible, curtail hiking activities for a day or two, and let the situation settle, or the blood collection might increase.

When a fingertip is smashed between two objects, there is frequently a rapid blue discoloration of the fingernail, which is caused by a collection of blood underneath the nail. Pain from the pressure may be quite severe. If the pain is intolerable, it is necessary to create a small hole in the nail directly over the collection of blood, to allow the blood to drain and thus relieve the pressure. This can be done during the first 24 to 48 hours following the injury by heating a paper clip or similar-diameter metal wire to red-hot temperature in a flame (taking care not to burn your fingers while holding the other end of the wire; use a needle-nose pliers, if available) and quickly pressing it through the nail. Another technique is to drill a small hole in the nail by twirling a scalpel blade, sharp knife, or needle. As soon as the nail is penetrated, blood will spurt out, and the pain will be considerably lessened. Before and after the procedure, the finger should be washed carefully. If the procedure was not performed under sterile conditions, administer an antibiotic (such as dicloxacillin, erythromycin or cephalexin) for 3 days.

In the case of my toe (above), the pain subsided with a day’s rest from hiking, so there was no benefit to be obtained by draining the blood. A new nail grew in underneath the one shown in the picture, with the entire process taking a full nine months from injury to nail replacement.

This post, Blood Under The Nail – What To Do, was originally published on Healthine.com by Paul Auerbach, M.D..

Media Malpractice: H1N1 Fear Mongering In NYC

July 27th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network, News, Opinion

Tags: CDC, Emergency Medicine, Flu, H1N1, Infectious Disease, media, New York City, Pulmonology, Social Media, Twitter

Friends visiting New York City this summer keep asking if it’s safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.

I like to think my friends are pretty sharp, discerning folks (after all, they’re choosing my company) so I have to attribute these inappropriate questions to a wider problem.

For reference, here’s the latest and thought probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.

This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I’m guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.

So why were ED’s swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:

…with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.

The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.

…The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.

All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process…

Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They’ve decided it’s just not in their interest.

I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.

There are many factors driving the public appetite for health risk information — and that’s understandable. I think it’s even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.

But what happened in NYC this spring was media malpractice — night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasion in which a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority — by the next day the lead story was ED’s are overcrowded and schools are closing.

EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.

But I’m more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.

It wasn’t enough to help ED’s this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It’s really the first good viral news I’ve heard in a while.

*This blog post was originally published at Blogborygmi*

Robot-Assisted Surgery Has Poorer Outcomes And Is More Expensive – But Because It’s Cool, We’ll Use It Anyway?

July 27th, 2009 by DrWes in Better Health Network, Health Policy, News

Tags: Cardiology, Cardiothoracic Surgery, Cleveland Clinic, Costs, Finance, MedPAC, Robotics, Surgery

Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.

I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it’s more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.

So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technology cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deleterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multi-center trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won’t be, will it?

Probably.

But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?

Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.

Now that might make for some really interesting reading.

*This blog post was originally published at Dr. Wes*