November 19th, 2009 by Dr. Val Jones in Health Policy, Opinion
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I was having an interesting Twitter chat with online friends (Liz Cohen @, Dr. Chuk Onyeije @; Dr. David Gorski @gorskon; Dr. Marya Zilberberg @murzee; Sherry Reynolds @cascadia; and @speakhealth) about the mammogram debate. They asked me “where I drew the line” on paying for expensive screening tests that may save lives but require unnecessary surgery for countless others. My opinion takes into account human nature and political savvy rather than pure science and statistics on this one.
To me, the bottom line is that the mammogram is a sloppy screening test. It’s expensive, there are lots of false positives and unnecessary surgeries, yet it saves occasional lives (which is dramatic and meaningful). We have to appreciate that women have come to accept the risks/benefits of this test, and have been told for a long time that they should begin screening at age 40.
It’s not emotionally or politically possible to reverse course on this recommendation until a better choice is available. You can trade the mammogram for a better test, but you can’t trade it for doing nothing. The amount of drama associated with the perception of having something potentially life-saving taken away is just not worth the cost savings. It may be a reasonable value judgment based on the data, but it’s not politically feasible so we should mentally take it off the table. Read more »
November 18th, 2009 by Dr. Val Jones in Audio, Expert Interviews, News, Research
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Dr. Avrum Bluming is a medical oncologist and clinical professor of medicine at the University of Southern California. He is also a dear friend, scientist, and careful analyzer of data. I asked him to help me understand the current mammogram guidelines debate, and what women (now faced with conflicting recommendations) should do about breast cancer screening. Please listen to his fascinating discussion captured here:
[audio:https://getbetterhealth.com/wp-content/uploads/2009/11/mammogrambluming.mp3]
What I learned is that the guidelines must be tailored to each woman’s unique situation. The variables that must be considered are incredibly complex, as breast cancer risk factors include everything from when and if one has given birth, to a history of smoking, drinking, overweight, breast cancer in the family and even the age of your parents when you were born. Beyond risk factors, new research suggests that some breast cancers spontaneously resolve without treatment, but our technology is not advanced enough to distinguish those from others that will go on to become life-threatening tumors – so we treat all cancers the same. Read more »
May 30th, 2009 by DrRich in Better Health Network, Opinion
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Earlier this year, DrRich offered several potential strategies for doctors and patients to consider, should healthcare reformers ultimately decree it illegal for Americans to seek medical care outside the new universal system. This eventuality (i.e., making it a crime to spend your own money on your own healthcare) may not be as far fetched as one might think at first glance, since in societies where social justice is the ultimate goal, such individual prerogatives must be criminalized.
At that time, DrRich offered several creative solutions to this problem, including offshore, state-of-the-art medical centers on old aircraft carriers, and combination Casino/Hospitals on the sovereign soil of Native American reservations. A reader subsequently offered the possibility of simply establishing institutions something like the “Cleveland Clinic Tijuana,” i.e., cutting-edge medical centers just south of the border. (This solution would have the added advantage of encouraging the government to finally close the borders once and for all, employing whatever means it might take, including military patrols, minefields, and missle-armed drone aircraft.)
As entertaining as it might be to imagine such solutions, a readily available, though much more mundane, solution exists today – medical tourism.
Medical tourism, where one travels outside one’s country in order to obtain medical care elsewhere, is a booming business. A number of superb state-of-the-art medical centers expressly aimed at attracting medical tourists have been established in the Middle East, Singapore, India, China and elsewhere in Asia. These institutions cater to citizens of the world whose own healthcare systems cannot (or will not) provide in a timely fashion (or at all) the level of care patients may desire. They offer modern hospitals, numerous amenities, luxurious accommodations, attentive nursing care, top-notch doctors – and they do it all for a tiny fraction of what the same care might cost (if you can even find it) in the U.S. and other “first world” nations.
Obviously medical tourism is not particularly feasible for medical emergencies such as heart attack or stroke, or for chronic illnesses such as diabetes, congestive heart failure, or Parkinson’s disease, which require frequent visits and long-term management. What is feasible is to become a medical tourist for those one-time medical services that can be scheduled and planned, for which there is a long waiting period at home, or which is simply too expensive in one’s own country. Such medical services often include coronary artery bypass surgery, hip replacements, knee replacements, and numerous minimally-invasive and not-so-minimally-invasive surgical procedures. In other words, medical tourism to a large extent is something one does for elective (i.e., non-emergency) surgery.
It ought not be a surprise, therefore, that the first organization of American physicians to issue a formal policy statement regarding medical tourism is the American College of Surgeons.
The reaction of American surgeons to medical tourism ought to be obvious. They hate it. Elective surgical procedures – the very procedures for which Americans become tourists – are the bread and butter of most surgical specialties. And here go their prospective patients, off to Singapore for their lucrative bypass surgeries. American cardiac surgeons, for instance (already underemployed, thanks to American cardiologists throwing stents at every tiny coronary artery indentation they they can justify as a “blockage”), are nearly apoplectic at the idea.
It’s always fun to read formal policy statements which attempt to deliver an entirely self-serving message whose essence is, “We hate this and if you do it we’ll hate you,” but in which it is necessary to deliver the message in a polite, politically correct, non-judgmental, helpful and even friendly manner.
The surgeons in general have made a good effort, as you can see if you’d like to read the policy statement for yourself. It’s pretty much what you would expect – “Go ahead and have your knee replaced in Timbuktu if you want to. It’s your right, so go ahead and devil take the hindmost. Just don’t come crying to me when things go south a month later.” Only, of course, the surgeons employ the obligatory very polite and professional tone.
DrRich is struck by two aspects of the surgeon’s policy statement on medical tourism.
First, the surgeons begin with a litany of dire warnings regarding all the medical considerations one must take into account before trusting one’s health to foreign medical hands:
“Some of the intangible risks include variability in the training of medical and allied health professionals; differences in the standards to which medical institutions are held; potential difficulties associated with treatment far from family and friends; differences in transparency surrounding patient discussions; the approach to interpretation of test results; the accuracy and completeness of medical records; the lack of support networks, should longer-term care be needed; the lack of opportunity for follow-up care by treating physicians and surgeons; and the exposure to endemic diseases prevalent in certain countries. Language and cultural barriers may impair communication with physicians and other caregivers.”
These are all very important considerations. DrRich notes, however, that these very same considerations (even the warning about endemic diseases, once one allows for the MRSA infections which are secretly “endemic” in some American hospitals) must also be taken into account before agreeing to receive care even in an American institution. It may be that these considerations are more an issue in top-notch foreign hospitals than in your average American hospital, but DrRich is not convinced this is the case, and the surgeons do not provide any evidence that it is. That is, DrRich sees this very good advice as being equally applicable whether one is considering becoming a medical tourist, or just a typical American patient.
Second, and most astoundingly, DrRich notes – not so much with interest, but more with awe – that the surgeons are beseeching their patients to consider just how difficult it might be to launch a malpractice suit against foreign doctors. (DrRich himself does not know how difficult this would be. Given that we are being so strongly urged these days to merge the American legal system with international law, it might not be much of a problem for long.) Indeed, the potential difficulty in suing foreign doctors appears to be the chief differentiator, and the primary argument in favor of good-old-American-surgery. The surgeons, in essence, are saying, “Let us do your surgery, because we’re easier to sue if we screw up.”
This, from the very body of American physicians who are most at risk for malpractice suits, and who traditionally have been most vociferous in favor of malpractice reform.
DrRich can only shake his head in wonderment. If medical tourism is viewed by surgeons as such a dire threat that they are formally embracing medical malpractice suits as their chief weapon against it, then medical tourism must have already caught on far more than most of us realize.
Which means, of course, that when healthcare reform takes place, medical tourism will likely enter a phase of truly explosive growth.
And so, Dear Reader, thanks to this critical clue provided by our friends in the American College of Surgeons, DrRich can confidently offer yet another nugget of investment advice. He formally recommends the medical tourism industry – now in its infancy – as an area ripe for growth.
*This blog post was originally published at The Covert Rationing Blog*
