February 3rd, 2008 by Dr. Val Jones in Health Policy, Medblogger Shout Outs
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One of my favorite healthcare policy blogs is Dr. Rich’s Covert Rationing. In his most recent post he discusses a research study linking New York State’s public report card system to increased heart patient death rates. Doctors’ names are published alongside their procedure-related mortality figures, so if a patient dies while undergoing a risky (though potentially life-saving) procedure, the doctor’s grade suffers.
It’s no surprise that doctors are more hesitant to operate on high risk patients if their professional reputation is on the line. The result is that patients with heart problems in New York State are less likely to receive life saving therapies.
Now here’s where my outrage increased exponentially – Dr. Rich argues that report cards are actively promoted by payers (health insurance companies and the government) under the guise of patient empowerment (they deserve transparency about their doctors’ performance record, right?) But the real truth is that the payers are benefiting financially from the report card system. Fewer procedures mean lower pay outs, and if high risk patients die sooner, then they save even more on care costs.
Man, that’s depressing. So many reforms with “good intentions” result in unanticipated harm. Though strangely I can’t think of too many reforms that harm the payers. Can you?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
February 1st, 2008 by Dr. Val Jones in True Stories
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For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.
Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:
Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.
Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.
So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.
Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.
How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.
There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?
This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.
I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.
What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 31st, 2008 by Dr. Val Jones in News
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Tonight (Jan 31, 2008) the CBS evening news will be airing a segment about a tragic case of a young Marine who died of melanoma. According to the news transcript, an unusual mole was diagnosed as a melanoma in 1997, but no follow up was scheduled, and no explanation given to the young man about his diagnosis or treatment plan. Eight years later in Iraq he complained to medical personnel of the mole growing larger and he was told it was a wart which would be treated once he returned to US soil. He slipped through the cracks somehow, and tragically died in 2008 of stage IV melanoma.
One interesting issue raised in the segment is that the Marine was not eligible to to sue for negligence in his case. There is a law, the Feres Doctrine, that denies military personnel the right to sue the government in cases of perceived or real medical malpractice. The rule was established in 1950 after a case was brought to the U.S. Supreme Court (Feres v. United States) in which servicemen who picked up highly radioactive weapons fragments from a crashed airplane were not permitted to recover damages from the government.
While I do understand (in theory) the purpose of this law – if every battle injury allowed soldiers to sue the government, we’d bankrupt our country in the span of a year – it does seem to be over-reaching in this case. The Marine was not injured in battle, but his life was indeed compromised by sloppy medical follow up. In my opinion, the doctor who correctly diagnosed him in 1997 should be held accountable for lack of follow up (if that’s indeed what happened). As for the military personnel who thought the Marine’s advanced melanoma was a wart, that is a tragic misdiagnosis, but hard to say that there was malpractice at play. With limited access to diagnostic pathology services, it is difficult (in the field) to be sure of the diagnosis of a skin lesion. And yes, I can imagine that an advanced melanoma could look wart-like. This is a tragic shame, but since the young man had the melanoma for 8 years prior to the misdiagnosis of the “wart,” in the end I doubt that a correct diagnosis at that point would have changed his terminal outcome.
But I wonder if the Feres Doctrine should be modified to allow for more accountability amongst military physicians in caring for diseases and conditions unrelated to military service? Although I am not pro-lawsuit, it does seem unfair that this Marine was denied the opportunity to pursue justice in his case. What do you think? Check out the segment with Katie Couric tonight and let’s discuss.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 29th, 2008 by Dr. Val Jones in Health Policy
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I attended an excellent brown bag lunch with Dr. Greg Downing today. He’s the program director for the U.S. Department of Health and Human Services’ (HHS) Personalized Health Care Initiative. He spoke about some of the challenges associated with incorporating genetic test results into a personalized health record, and how consumer demand is fueling biotech companies to offer tests long before their clinical significance has been determined.
Here are some interesting statistics that Dr. Downing mentioned:
Only 15% of Americans have their medical records in an electronic format that they can access
About 30% of clinical decisions are based upon evidence from quality research
At least 70% of genetic tests are requested by patients, rather than clinicians
At the same time, HSS Secretary Mike Leavitt has issued this vision statement about personalized health care:
“Personalized health care is providing the right treatment, for the right patient, for the first time, every time.”
So what we have here is an incredible gap between our aspirations and reality. While we want to leverage genetic information for disease prevention purposes, subjecting the entire population to a “needle in a haystack” search for disease predictors is extremely expensive. In addition, genes rarely provide black and white answers regarding disease risk. Sure there’s the Huntington’s Disease gene (which really does have a nearly 100% correlation with the development of the disease), but the vast majority of genes have much more gray significance, with shades of predisposition and uncertainty.
Biotech companies sense America’s eagerness to peer into its health future, and are actively engaged in direct to consumer advertising. With tests ranging in price from $300-$3000 dollars, and wealthier clients willing to pay for the tests, they stand to make a good profit without clear improvements in health outcomes, or patients even knowing how to interpret their results.
Connecticut Attorney General Richard Blumenthal (D) recently said his office is investigating the accuracy of claims Myriad makes about the test in the ads, including issuing a subpoena for information about the ads. Blumenthal said his office has received complaints from professional caregivers, clinicians and scientists who believe the test has a “very high potential for misinterpretation and overreaction.”
In a rather extreme case of putting the cart before the horse, a potential susceptibility to suicidality (while on particular anti-depressants) was linked to a certain gene sequence. The day after the publication of this preliminary research one company was offering the genetic test directly to patients for $500/test.
So ultimately I agree with Dr. Downing’s cautionary message: let evidence based medicine be the foundation upon which personalized medicine is built. Mad dashes for genetic enlightenment don’t mean much if we don’t know how to interpret the test results. And let’s not forget the role of environmental factors in our health. You may have longevity genes, but if you’re engaged in risky behaviors, what good are they?
I do believe that the study of genetics is critical to our understanding of health and disease, but we need to do the research to learn how to leverage what we learn. Research is costly and slow, but the rewards are worth the investment. If you are going to undergo genetic testing online, make sure that you do so with a reputable company like DNA Direct that offers evidence-based tests with genetic counseling as part of the package, so that you will know what your test(s) mean. Of course, the best plan is to discuss genetic testing with your doctor.
And as for Secretary Leavitt, I applaud his vision and look forward to the day when we’ll all have access to our health information online, and we’ll receive the right treatments at the right time, every time… Let’s just say we’re not there yet.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 29th, 2008 by Dr. Val Jones in Celebrity Interviews, Opinion
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I’ve been wrestling for some time about whether or not it’s appropriate to blog about celebrity news (particularly health issues). On the one hand it seems like an invasion of privacy – what gives me the right to speculate on their health? Shouldn’t I leave the poor celebs their privacy, hen pecked as they are by the media? Yet, on the other hand, when the country is abuzz about an important health issue, there is a “teachable moment” in which doctors can perhaps influence patient lifestyle choices for the better, or encourage some preventive screening if needed.
I did decide to blog about Heath Ledger’s sad passing, and thought it might be important for people to know about autopsies and how they work. Although I had mixed feelings about the post, it was one of my most popular in a long time. So that led me to conclude that I shouldn’t shy away from celebrity news. Nonetheless, I confessed my squeamishness to a friend of mine, and his answer was so insightful that I thought I’d share it with you:
The other way I think
of it is this: health is really personal. Almost everyone who writes about
health does it from the perspective of a personal story – the most common health
blogs are health blogs by patients / survivors about their own experience, the
next most common is by doctors talking about patients. You could have written
yesterday’s entry [Heath Ledger] about the death of a friend or a patient under unknown
circumstances. The problem is that a blog that begins every time with, “I had a
friend who had ALS…” is very concrete to you – you know the friend – but not
concrete to the reader – they don’t know your friend. The use of celebrities
creates a shared vocabulary – people we all “know” that we can converse about.
Put another way, in an
era before blogs, where health conversations were held around kitchen tables and
over the back fence, there was probably less discussion of celebrity health
because the discussants all shared a common stock of people about whom to chat:
Doris down the street has breast cancer; Trudy two doors down has a pregnant
teen; Francine on Maple Street has a mom with Alzheimer’s. The internet and
blogs are an attempt to create a similar conversation with people all over the
country – the planet – who don’t know any people in common. Celebrities are the
only folks we can all discuss, because they are the only folks we all
know.
What do you think? Is it ok to blog about celebrities? Should I do more of it? Less of it? Does my friend have a point? Please share your thoughts.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
