It’s not every day that a physician is invited to be screened for chronic obstructive pulmonary disease (COPD) by a comedian. But this event was no joke – actor Jim Belushi is in a contest with Danica Patrick, Bruce Jenner, Patty Loveless, and Michael Strahan to see who can get the most Americans screened for COPD. It’s a tough race for a good cause – though I’m not sure if Jim stands much of a chance in a competition against Danica Patrick. Maybe my blog readers will vote for Jim and give him the bump needed to keep him in the running? Please take the screening test here, or forward it to friends who may be at risk (age over 35, history of smoking).
Like any good blogger, I had my trusty digital recorder with me and got in a few questions with Jim. Special thanks to South African blogger Delre Roberts, who gave me the idea for my leading joke to Jim via Facebook: “How’s a comedian going to screen a doctor for COPD? See how short of breath she gets from his jokes?” Good one, Delre! You got a laugh out of Jim… Check it out:
[Audio:https://getbetterhealth.com/wp-content/uploads/2010/02/jimbelushicopd.mp3] Read more »
Susie Essman, aka Susie Greene of Larry David’s HBO program, “Curb Your Enthusiasm,” has written a hilarious book (and yes, I actually read it) called What Would Susie Say?: Bullsh*t Wisdom About Love, Life and Comedy. For this week’s CBS Doc Dot Com, I talked to Susie about some of her health issues covered in the book, including menopause, fear of germs, and hypochondria. “So far this month,” she told me, “I’ve had Lyme disease, hysterical blindness, enlarged prostate….”
If any woman could actually have an enlarged prostate – either her own or snatched in a fit of pique from her beleaguered television husband played by Jeff Garlin – it would be Susie Green. But as we discussed her real and imagined symptoms, it became clear that Susie Essman can be easily talked down from her flashes of hypochondriacal thinking. So she doesn’t actually meet the official psychiatric definition of “hypochondriasis,” in which a misinterpretation of symptoms leads to a preoccupation with having a serious illness that interferes with daily functions and lasts at least six months despite reassurances from a doctor. In fact, her belief that she’s a hypochondriac is hypochondriacal. Read more »
My Interview With President Obama On Health Care Reform
I met President Obama yesterday. I interviewed him at the White House about his proposals for health care reform. But naturally, as we greeted each other, I asked about his throwing out the first ball at the All Star Game the night before.
“Were you nervous about bouncing the ball?” I asked. He grinned. “I will say it’s actually nerve-wracking,” he said. “When they hand you the ball, there are just a lot of things that can go wrong.” I found that to be a perfect metaphor for his assuming the Presidency of the United States and attempting to overhaul the health care system.
The biggest news from yesterday’s interview: President Obama has changed his position from the campaign trail and now believes that health care insurance should be mandated for all Americans, with a hardship exemption.
Dr. LaPook: Ultimately, philosophically, do you believe that each individual American should be required to have health insurance?
President Obama: I have come to that conclusion. During the campaign, I was opposed to this idea because my general attitude was the reason people don’t have health insurance is not because they don’t want it, but because they can’t afford it. And if you make it affordable, then they will come. I’ve been persuaded that there are enough young uninsured people who are cheap to cover, but are opting out. To make sure that those folks are part of the overall pool is the best way to make sure that all of our premiums go down. I am now in favor of some sort of individual mandate as long as there’s a hardship exemption. If somebody truly just can’t afford health insurance even with the subsidies that the government is now providing, we don’t want to double penalize them. We want to phase this in, in a way that we have time to make sure that coverage is actually affordable before we’re saying to people “go out and get it.”
The interview went very smoothly and fairly predictably until we reached the following exchange:
Dr. LaPook: You’ve said that if doctors have the information, they’ll do the right thing. And generally, I like to — I’m a physician and practicing — I think that’s true. But actually, there are a lot of times when that’s not the case. For example, angioplasties — elective angioplasties, where you open up a clogged artery in the heart. It turns out that about 30 percent of them are unnecessary, that they’re done and you try to open up an artery of the heart, but really it’s no better than medication, and doctors know this, but they still order them.
President Obama: Why are they still ordering them, do you think?
I will admit that he took me by surprise by turning the question on me. Suddenly I was not in a one-way interview, I was in a conversation. Politics aside, it was clear to me that he was listening and he was curious.
Dr. LaPook: I think that because they believe — there’s this thing about — if an artery’s closed. It’s got to be better if it’s open, and it turns out that’s not true. So they have on the one side their intuition as a physician, in their bellies, and then there’s the evidence-based medicine that we talk about, and they clash a lot at times, so how do you make that doctor do the right thing or give him the right incentives?
President Obama: I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we’re honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we’re reimbursing the physician not on the basis of how many procedures you’re performing but rather how are you caring for the patient overall – what are the outcomes – then I think you start seeing some different choices. And at the very least, you’re not taking money out of physicians’ pockets for making the better choice. So it’s a combination of better information and then, I think, a different system of reimbursement that says, “let’s look at the overall quality of the care of the patient.”
My conversation with President Obama illustrates a crucial focus of the current healthcare debate: figuring out if the American people are getting their bang for the buck when doctors order tests, perform procedures, and prescribe medications. The current buzzwords among doctors and politicians are “evidence-based medicine” (is there proof that something works?) and “comparative effectiveness” (if there’s more than one way to do something, what works best?). An Institute of Medicine workshop about evidence-based medicine began today in Washington, with the following listed as “issues prompting the discussion”:
. “Health costs in the United States this year will be about $2.5 trillion—nearly 17% of the economy.
. The United States spends far more on health care than any other nation, 50% more than the 2nd highest spender and about twice as high as the average for other developed countries.
. Overall health outcomes in the United States lag behind those achieved in other countries.
. Consistent with the per capita figures, many researchers studying the nature of U.S. health expenditures feel that 20% of our expenditures do not contribute to better health.”
Expert groups are currently trying to establish guidelines for reimbursing health expenses based on clear results from well-designed clinical studies. The problem is that for many medical issues, there is no definitive, evidence-based approach. Clinical medicine is often based on inexact, immeasurable tools such as intuition and experience. As doctors, we don’t have the luxury of waiting for the twenty-year study to be completed. We have to treat the patient now, as best we can, without perfect information.
In the absence of definitive data, we will need to account for clinical judgment in an overhauled health care system. What will happen when the doctor suggests something the insurance company says is not indicated? Opponents of a public option for insurance warn about the danger of having a bureaucrat in between the patient and the physician. But that threat already exists in the current system every time an insurance company decides whether to approve a claim. Wendell Potter, former head of Public Relations for Cigna, recently told
Bill Moyers about Cigna’s decision to deny a liver transplant to a 17-year-old girl, Nataline Sarkisyan, even though her doctors at UCLA had recommended the procedure.
A public-relations uproar forced Cigna to reverse its decision; the company subsequently explained its reversal as an exception, saying the surgery was approved “despite the lack of medical evidence regarding the effectiveness of such treatment.”
Ms. Sarkisyan died hours after Cigna’s decision, without having received the transplant.
A critical flaw in the current system – and one that must be addressed in any overhaul – is that the same people who refuse to pay for a recommended course of action are the ones who consider the appeal of that decision. And, lo and behold, they usually end up agreeing with themselves! In more than two decades of medical practice, I have spent countless hours trying to get various services covered by payors. One encounter – when I tried unsuccessfully to get a stomach-acid lowering pill approved for a patient who needed it -ended up as an example of twentieth-century frustration in
Letters of the Century.
Yes, our current health care system is not sustainable and we do need an overhaul. But there is no “exactly how” and we cannot afford to wait for one. There are so many nuances to the moving target of health care and so many unknowns that it is impossible to create a perfect solution on paper. I’ll settle for an imperfect solution that addresses the most important problems first and represents the best efforts of our most thoughtful experts. But it should not be set in stone. It must include provisions to mature gracefully into versions 2.0 and beyond.
New Media guru Clay Shirky was the keynote speaker at the Management of Change conference in Norfolk, Virginia. His recent book, Here Comes Everybody, is considered a must-read by most web 2.0 enthusiasts. Clay and I escaped the conference for a tête-á-tête at a local Starbucks where we wrestled with the thorny issues of healthcare and crowd sourcing.
Dr. Val: I’ve noticed that there is a difference between being right and being influential. Doctors are having a hard time adjusting their tone to be more compelling in a social media culture. What do you think physicians can do to be more influential online?
Shirky: The problem is that, since we all die eventually, everyone will be unhappy with their healthcare at some point. This creates a social dilemma that’s neither transitory nor small. First, there will always be snake oil salesmen peddling “eternal life,” and second, there will always be an unhappy faction who rail against the medical establishment. You should not try to stamp out that faction, but referee it. Federalist Papers No. 10 states that faction is the normal case of government – the trick is not to allow factions to gain disproportionate power. Physicians need to realize that patients have different priorities than they do, and speak to those as much as possible.
Dr. Val: What do you mean that we have different priorities?
Shirky: Take Medpedia for example – physicians are eager to write about rare types of liver cancer, but they don’t want to write about the basics of biopsy technique. For the physician, it’s perfectly obvious what a liver biopsy entails, so he/she doesn’t think to write about it. But the patient is probably more interested in learning about biopsy procedure than the scientific details of a rare liver cancer. The entries in Medpedia strongly reflect physician interests and priorities, though the resource is ultimately supposed to serve the educational needs of patients.
Dr. Val: What’s the best way to close that gap in priorities?
Shirky: We need to fuse the conversation between physicians and patients. The more they work together, the more valuable the content will be.
Dr. Val: What do you think about the trend towards “user-generated healthcare?”
Shirky: It’s important to have checks and balances. When lay people discuss medicine, their unguided conversation can degenerate into vitamin hucksterism. I think that whole movement was initiated when the FDA decided not to regulate the supplement industry – people have been used to getting input from others who aren’t scientifically qualified. Now everyone gives medical advice, and people listen.
Social media is a very new phenomenon. We have not figured out how to apply good checks and balances yet – amateurs’ opinions and voices can drown out the experts. We want to believe that everyone’s opinion is equally valid – but that’s just not the case. In the end, quality and clarity of messaging is a source of power.
I had the recent honor and privilege of having dinner with Mort Kondracke and his gracious wife Marguerite. Mort’s TV show, The Beltway Boys, offers entertaining and insightful political commentary each weekend.
Mort and I share a common medical interest: Parkinson’s Disease. Mort wrote an excellent book about his late wife’s battle with Parkinson’s. It’s called Saving Millie: Love, Politics, and Parkinson’s Disease. My experience working with patients with the disease has led me to become a supporter of the Parkinson’s Action Network (PAN). I look forward to seeing Mort at future PAN events, and I hope that the recent increase in funding to NIH will help to advance research in Parkinson’s Disease so that we may one day find a cure.
Also at the dinner: PAN CEO Amy Comstock Rick, Robin and Brian Strongin, and my husband Steve. Mort shared some personal perspectives on the famous political figures he’s interviewed over the years – and we compared notes on what they’re really like. Of course I won’t reveal the unsavory stories, but what I can say is that we both agreed that Bob Schieffer is one of the nicest people on earth. Go Bob!
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It’s not every day that a physician is invited to be screened for chronic obstructive pulmonary disease (COPD) by a comedian. But this event was no joke – actor Jim Belushi is in a contest with Danica Patrick, Bruce Jenner, Patty Loveless, and Michael Strahan to see who can get the most Americans screened for COPD. It’s a tough race for a good cause – though I’m not sure if Jim stands much of a chance in a competition against Danica Patrick. Maybe my blog readers will vote for Jim and give him the bump needed to keep him in the running? Please take the screening test here, or forward it to friends who may be at risk (age over 35, history of smoking).
