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Normal People Have Abnormal Brain MRIs

A recent research study suggests that as many as 7% of adults over 45 have had a stroke without even realizing it. Researchers performed brain MRI scans of 2000 “normal” (asymptomatic) Dutch men and women between the ages of 45 and 96, and found that 7.2% of them (145 people) had evidence of an infarct (stroke), 1.8% (36 people) had small aneurysms, and 1.6% (32 people) had benign tumors (usually a small malformation of the blood supply to the brain).

Interestingly, they also found one person with a primary brain cancer, one person with a previously undiagnosed lung cancer that had metastasized to the brain, one person with a life-threatening subdural hematoma (brain bleed), and one person with an aneurysm large enough to require surgery. So altogether, they found 4 people out of 2000 who needed urgent medical intervention.

Although the authors of the article emphasized the point that many “normal” people have harmless brain abnormalities – I was a bit surprised by the fact that they found 4 asymptomatic people unaware of a ticking time bomb in their brains.

Keep in mind that the study was conducted on middle class Caucasian adults in the Netherlands – so we cannot generalize these findings to more diverse populations. But I do think it’s a bit of an eye-opener.

MRI scans are quite expensive (well over $1000 in most cases) and are therefore not offered to the general population as a screening test. But it does make you think about saving up for one. Your radiologist may find something unimportant, or she may find something that you hadn’t bargained for. Or maybe one day the technology will be inexpensive enough to offer as a screening test in a primary care setting. But that’s not going to happen any time soon.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

What Does Labor Day Have To Do With Doctors?

Labor Day was founded in the late 1800’s as a way to thank
American workers (as Peter J. McGuire, a cofounder of the American Federation
of Labor put it): “who from rude nature have delved and carved all the grandeur
we behold.”  There is some debate
about who originated the concept of the holiday, but one truth remains:

“All other
holidays are in a more or less degree connected with conflicts and battles of
man’s prowess over man, of strife and discord for greed and power, of glories
achieved by one nation over another. Labor Day…is devoted to no man, living
or dead, to no sect, race, or nation…  It
constitutes a yearly national tribute to the contributions workers have made to
the strength, prosperity, and well-being of our country.”

Resident physicians are on my mind with Labor Day
approaching. I know that they are toiling away in hospitals across the nation,
and many of them do not get to take Labor Day off for vacation.  Physicians work for 3-7 years after
graduating from medical school, and are paid (on average) about the equivalent
of a home health aide or a medical secretary but work about twice the hours
during residency.  In fact, if you calculate
out the salary by the hours they work, resident physicians are paid about $9
-$10/hour which is roughly $1.50 more than minimum wage.

Not surprisingly, resident physicians have joined unions to
lobby for more reasonable wages and caps on the number of hours they must work
per week.  The national cap is now at 80
hours per week – about 20 hours more than a truck driver is allowed to work
(for “safety reasons”).  Research from Harvard
suggests that errors made by overworked residents increase by 700% when they
have worked more than 24 hours in a row.

Residents from the University of New Mexico, for example, received wages in the lowest 1% for resident physicians in their region, and
were denied a salary increase until they recently joined forces with CIR (the Committee of Interns and Residents) to
negotiate more reasonable salaries and working conditions.  The New
Mexico contract adds one more CIR chapter to the more
than 70 hospitals — each with multiple residency programs — that are part of
CIR.

Founded in 1957 to improve patient care and resident working
conditions, CIR has remained true to those two goals throughout the decades. In
1975, CIR won an end to every other night on-call in New
York City, and created the first-ever Patient Care Fund in Los Angeles, where
residents could purchase equipment or create innovative programs to help
patients. Campaigns to prevent needle stick accidents by moving to safer needles,
or needle-less equipment, have also improved working conditions for residents.

CIR has been on the forefront of safe and humane work hours
for residents, helping to win the 80 hour regulations in New York State
in 1989, which became the foundation for the 2003 national guidelines. But
evidence shows that this is still too many hours, and so the advocacy around
hours continues unabated.

So please have safe travels on your Labor Day weekend – we
wouldn’t want you to wind up at a hospital where the residents work more than
24 hours in a row for ~$9/hour.  Resident
physicians are one group of laborers who don’t have much to celebrate yet this
Labor Day.  But with CIR’s help, next
year might be a little brighter.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Preventive Care Can Keep You Out Of The Hospital

In a recent study conducted by the Agency for Healthcare Research and Quality (AHRQ), it was argued that better primary care could prevent 4 million hospitalizations per year.  This staggering potential savings – on the order of tens of billions of dollars – seems like a good place to start in reducing some of the burden on the healthcare system (and reducing unnecessary pain and suffering).  I interviewed Dr. Joe Scherger, Clinical Professor of Family & Preventive Medicine at the University of California, San Diego School of Medicine (UCSD) and member of the Institute of Medicine, to get his take on the importance of prevention in reducing health costs.

Dr. Val:  What do the AHRQ
statistics tell us about the role of primary care in reducing healthcare
costs?

Volumes!

Primary care works with the
patient early in the course of illness, maybe even before it has developed, such
as with prehypertension and prediabetes.  Primary care focused on prevention
with patients keeps people healthier and out of the
hospital.

Dr. Val: What can individual
Americans do to reduce their likelihood of having to be admitted to the
hospital?

Prevention begins with the individual,
not the physician.  60% of disease is related to lifestyle.  Bad habits such as
smoking, overeating, not being physically fit, and stress underlie most common
chronic diseases.  If Americans choose to be healthy and work at it, we would
save tremendously in medical expenses.

Dr. Val: Are there other studies
to suggest that having a medical home (with a PCP) can improve
health?

The medical home concept is new and lacks
studies, but the work of Barbara Starfield and others have confirmed the
importance of primary care and having a continuity relationship with a primary
care physician.  The more primary is available, the healthier the population.
The opposite is true with specialty care.

Dr. Val: Why did the
“gatekeeper” movement (promoted by HMOs) fail, and what is the current role of
the family physician in the healthcare system?

The
“gatekeeper” role failed because it restricted patient choice.  Patients need to
be in control of the health care, which is what patient-centered care is all
about.  HMOs put the health insurance plan in charge, something which was hated
by patients and their physicians.

Dr. Val: In your work with the
IOM (specifically in Closing the Quality Chasm) did the role of primary care and
preventive medicine come up?  If so, what did the IOM think that PCPs would
contribute to quality improvement in healthcare?  Did they discuss (perhaps
tangentially) the cost issue (how to reduce costs by increasing preventive
measures?)

Just before the IOM Quality Reports
came out, the IOM did a major report on the importance of primary care.  The
importance of primary care and prevention are central to improved quality.  In
the “Chasm Report”, the focus was more on the patients taking greater charge of
their health care, and the realization that primary care is a team effort, and
not just a role for physicians.  The reduction in costs comes from making health
care more accessible (not dependent on visits) through health information
technology and the internet.  Preventing disease, and treating it early when it
comes, are the keys to quality and cost reduction.  Revolution Health is a
vehicle for this, consistent with the vision of the “Chasm Report.”

Dr. Val: How can patients be sure that they’re getting the best primary care?

First take charge of your
own primary care.  The traditional patient-physician relationship was, “Yes
doctor”, “Whatever you say doctor”.  Your care would be limited by the knowledge
and recall (on the spot) of your doctor.
Much better is a “shared care” relationship with your primary care
physician and team.  After all, the care is about you.  Be informed.  Make your
own decisions realizing that the physician and care team are advisors, coaches
in your care. You may agree with them, or disagree and do it your way.  By
having your own personal health record and being connected to resources like
Revolution Health, you are empowered to get the care you want and need.
Finally, choose your primary care wisely.  Not just anybody will do.  Your
primary care physician is as important a choice as your close friends.  You need
to like and trust this person.  Have a great primary care physician who knows
you and cares about you and your health care is in real good shape.  But, no
matter how good she or he is, you still must take responsibility for your care.


This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Don’t Get Sick in July?

One of my colleagues just forwarded me a NY Times article by Jerome Groopman.  The article begins with the issue of inexperienced interns – how newly minted MDs begin clinical care for patients in July of each year, and how these rookies can make harmful mistakes.

He goes on to explain that doctors aren’t trained to think well about the diagnostic process (the thesis of his recent book) and that we’d all benefit from studying cognitive psychology.

Dr. Groopman makes some interesting points in this article, but I was most struck by his flippancy regarding the dangers of getting treatment in July.  He simply says, “Today, most hospitals closely watch over interns.”

I personally think the issue is more sinister than that – there are many ways that an intern can make mistakes, without ordering a single test or procedure, and under the full scrutiny of red tape regulations and documentation practices.

When an intern fails to recognize a life threatening condition and chooses to do nothing, or to let the patient wait for an extended period of time before alerting his or her team to the issue, serious harm can befall that patient.  And that harm is not caused by inexperienced procedural technique, or ordering the wrong medicine – it’s caused by doing nothing.  This “doing nothing” is the most insidious of intern errors – and it is not remedied by any form of hospital quality improvement initiatives.  It is the risk that a hospital takes by having inexperienced physicians in the position of first responders.  Interns gather large amounts of information about patients and then create a summary report for their supervisors.  The supervisors (more senior residents) don’t have time to fact check every single case, and must rely on the intern’s priority hierarchy for delivering care.

But many hours pass between the time an intern examines a patient and when a supervising physician checks back in with that patient.  And within that period of time, many conditions can deteriorate substantially, resulting in the loss of precious intervention time.

Dr. Groopman describes an experience from his own life in which a surgical intern (in July) correctly diagnosed his son with an intussusception (twisted bowel) but then incorrectly determined that the baby could wait to go to the O.R.  Of course, untreated intussusceptions are nearly always fatal, and each minute that passes without intervention can increase the risk of death.

And so, in my opinion, it is in fact more dangerous to be admitted to a teaching hospital in July, but not necessarily for the reasons that people assume (procedures performed by inexperienced physicians or drug errors – though those mistakes can be made as well). Rather, it is because interns don’t have the clinical experience to know how to prioritize their to-do lists or when to notify a superior about a patient’s health issue.  Timing is critically important in quality care delivery – and that variable is not controlled by our current intern oversight system.

Now that I’ve completely terrified you – I will offer you a word of advice: designate a patient advocate for your loved one (or yourself) if you have to be in the hospital as an inpatient (especially in July).  If you can, find someone who is knowledgeable about medicine – and who knows how to navigate the hospital system.  A nurse, social worker, or physician are great choices.  That person will help you ensure that concerns are prioritized appropriately when your intern doesn’t yet fully appreciate the dangers behind certain signs symptoms.  If you have no advocate, then befriend staff members who are particularly caring and experienced.  Be very nice to them – but don’t be afraid to insist on being examined by the intern’s supervisor if you really are concerned.  Unfair as it may seem, sometimes the most vocal patients get the best care.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Hospital Quality Ratings

Dr. Richard Reece wrote a wonderful personal reflection on the value of hospital ratings.  As you may know, there has been much recent debate about their usefulness.  With all the different rating systems, a single hospital can be ranked #1 in the country by one source and middle of the pack by another.  It’s true that there are many variables to be considered, and that measuring quality is a tricky business.  But one would hope that if we were getting close to observing something real about a hospital, most different scoring systems would lead to the same general conclusion.

The fact that this isn’t the case yet says to me that there is a lot of work to be done in standardizing scoring, developing transparency in the system, and removing hospital marketing efforts from objective data.

I am glad that we’re beginning to shine the light on institutional quality, but there is an elephant in the room.  When it comes to good medicine, the most important factor is the individual healthcare provider.

I have personally witnessed outstanding medical care in the midst of hospitals with poor reputations, and I have observed horrific outcomes at top ranked hospitals as well.  What made the difference?  The provider taking care of the patient.

My insider perspective is that consumers are on the right track with physician ratings – worrying more about getting into the hands of a good doctor, than into the hands of the right hospital.  But physician ratings can be dangerous – if left open to the public without any form of moderation or intelligent analysis, one patient with borderline personality disorder and a grievance could hijack the rating system and destroy a physician’s public reputation.  Safeguards against that sort of behavior can and should be put in place.

The most helpful physician rating system will offer data from multiple sources (patient ratings, peer ratings, health plan ratings) and include sophisticated anti-sabotage algorithms.  It’s also important for the ratings to be protected from self-interests (so that the physician herself doesn’t game the system and use it as a marketing tactic).

Rating quality care is complex, and there will always be a subjective element to it.  Hospitals are run by flawed humans, healthcare providers make mistakes, and yet everyone wants the same thing: consistently excellent medical care.

And that will never happen – so long as humans are imperfect.

As Dr. Reece says,

Unfortunately, variable costs, variable quality, and variable outcomes
are a function of humanity, regional cultures and their constituencies.
Independent variables are part of the human condition. Some of these
variations may be beyond managerial control…

It’s going to take a while to establish criteria to judge and sort out
the good, the bad, and the ugly. Public disclosure of outcome data and
performance data on the processes of care may help, but they are only
part of a complicated human equation.
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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