June 29th, 2008 by Dr. Val Jones in Opinion
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I realize how incredibly tempting it is to reduce medicine to a series of algorithms. Wouldn’t it be nice if we didn’t need to see a doctor to diagnose our ills? Wouldn’t it be great if our computer could tell us what’s wrong, and prescribe next steps for us? Wouldn’t it save money if we could triage peoples’ medical needs without human intervention?
Unfortunately, we’re not there yet. A friend of mine posted a link (on Twitter) to an online triage tool called “FreeMD.” The tool describes itself this way:
FreeMD® is an electronic doctor that conducts an interview, analyzes symptoms, and provides expert advice — for free.
So I decided to try it out. I imagined that I was a hypothetical patient – a woman in her mid thirties who had had abdominal surgery in the past and was now experiencing mild to moderate abdominal pain. My imaginary patient has abdominal adhesions from the surgery, which is causing her to have bowel pain – which could become an obstruction and surgical emergency.
I answered all the questions posed by the free MD and he responded that he had determined the most likely cause of my pain: tubal pregnancy or threatened abortion.
This response was offered even after I indicated that I was not pregnant. What would the average consumer think of seeing “threatened abortion” as a potential diagnosis for their abdominal pain? Would they know that this was the medical term for miscarriage or would their mind race to abortion clinics and ominous threats?
The problem with this tool is that it cannot take into account all the subtle co-morbidities and nuanced historical information necessary to return an accurate result. In fact, no online tool can replace a healthcare provider’s evaluation of a patient. Attempting to do so is like playing Russian Roulette with your health. Maybe you’ll get lucky and happen upon the correct diagnosis and treatment, but maybe you’ll be horribly misled and suffer irreperable harm.
Of course, companies like freeMD contain disclaimers about the service not being a substitute for a physician’s oversight. But the reality is that people are using the service to make decisions about when and if to see a professional for further evaluation. As a concerned physician, I worry about patients being misled about their health. I want patients to be empowered and to learn all they can about their disease or condition – but self-diagnosis, even with the aid of an algorithm, is fraught with danger.
My bottom line: computers will replace physicians when robots replace spouses. Similar satisfaction rates will come from either replacement option. People know instinctively that a good doctor is critical in managing their health – why else would there be so many physician rating tools, including the one here at Revolution Health? Why would Castle Connolly bother to publish their yearly “America’s Top Doctors” reports? This is not about paternalism – it’s an acknowledgement of the incredible complexity of human beings. And in this case my friends, it takes one (doctor) to know one (patient).This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 7th, 2008 by Dr. Val Jones in Opinion
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Hot and humid weather has spurred on the growth of many of my outdoor plants, including bamboo, rosemary, and various peonies. However, I was unpleasantly surprised by the arrival of three fungal guests, only one of which I could identify: the dog stinkhorn. As its name suggests, it is one unpleasant-smelling organism. A certain mushroom website described it as looking like “a dog phallus dipped in excrement.” They are not too far off. But sadder still was the assertion that there is no known cure for this fungal invader.
As I considered my new mushroom issue, I suddenly realized that there are interesting parallels with the healthcare system. Let me explain.
First of all, what does the average person do when they experience a new medical symptom/problem? The person goes online to research the symptom for possible diagnoses and treatment options. Is s/he successful? Sometimes yes and sometimes no. In my case, I could only identify one of the three types of fungi in my garden, even after finding this very nice mushroom identifier tool. Why wasn’t I successful? I’m not a fungi expert, and really didn’t know how to navigate my way through the complex descriptors required to correctly identify the little beasts. The questions included the following:
Fungus Website (FW): Is the spore color olivacious?
Dr. Val: What part of the mushroom is the spore, and what kind of olive are you referring to? I don’t know how to answer that.
FW: Describe the stem type. Is it lateral, rudimentary, or absent? Does it have a volva?
Dr. Val: Um… If the stem is lateral, does that mean it’s sticking out of the side of the mushroom? What makes a stem rudimentary? Does that just mean it’s not fancy? And as for the last question… that sounds kind of pornographic and I don’t think I’d know a fungus volva if I saw one.
FW: Can the pore material be separated from the flesh of the cap?
Dr. Val: What’s pore material?
FW: Is the mushroom edible, hallucinogenic, or poisonous/suspect?
Dr. Val: Well, it definitely looks “suspect” but there’s no way I’m going to test it out for poisonous or hallucinogenic effects.
And so it went. I tried to answer some of the identifier questions to get me to the correct fungal I.D. and in the end I received this message, “we were unable to find a match for your search.”
When patients try to find a diagnosis for their symptoms online, they will inevitably have a similar experience. Medical speak is like a foreign language, subtle differences between signs and symptoms seem obvious to experts, but can be opaque to patients. And even a very bright and educated consumer is bound to get lost in figuring out appropriate next steps. I’m a savvy woman, but when it comes to mycology (the study of fungus), I’m completely lost. How much more complicated is it to navigate the subject of human disease for those who don’t have formal training in medicine?
My point is this – medicine is incredibly complex, and a knowlegeable heatlhcare provider is critical in helping patients successfully navigate the maze. With all the health information on the Internet, it’s tempting to self-diagnose. But that’s a dangerous proposition – one that might lead you to presume that (to use my analogy) a poisonous mushroom is edible, or that a life threatening symptom is innocuous.
The Internet can be a great educational tool, but use it in conjunction with a close relationship to a trusted expert. If you don’t have a primary care physician, you can find one here. If you’d like to have your question answered by a physician online, try the Revolution Health forums. Not every question is selected for a professional reply, but many are. For a guaranteed response, eDocAmerica is a great resource.
Good luck, and I hope that your garden remains fungus-free. I’m now going to try to find a mycologist to tell me if it’s really true that there’s “no cure” for the dog stinkhorn. Unless any of you know the answer?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 29th, 2008 by Dr. Val Jones in Medblogger Shout Outs
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Thanks to KevinMD and the folks at Science Based Medicine respectively, I have enjoyed a good belly laugh at the following:
1. A satirical website devoted to a new EMR system: “Extormity”
“At the confluence of extortion and conformity lies Extormity, the electronic health records mega-corporation dedicated to offering highly proprietary, difficult to customize and prohibitively expensive healthcare IT solutions. Our flagship product, the Extormity EMR Software Suite, was recently voted ‘Most Complex’ by readers of a leading healthcare industry publication.”
2. A video spoof of the TV show “ER,” but run by New Age therapists. It’s called “Homeopathy ER.”
3. And as a bonus website for those of you who may not have discovered it yet, engrish.com is full of amusing foreign signs and product messages in broken English.
I hope these sites get your endorphins going!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 26th, 2008 by Dr. Val Jones in Expert Interviews
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In my quest to bring the best possible health advice to the Revolution Health community I am actively pursuing interviews with credible sources. At the top of the list is America’s #1 doctor, the Surgeon General. I recently had the opportunity to sit down with Vice Admiral Richard H. Carmona, M.D., who served as Surgeon General from August 2002 to August 2006. He addressed a range of health issues facing Americans today. I am posting the interview in segments; the following post is part of that series.
Dr. Val: What role could consumer-directed healthcare initiatives play in helping to reduce healthcare costs associated with chronic disease? Is the government doing enough to support this movement?
Dr. Carmona: I think the consumer-driven initiatives struggle for a number of reasons, and the most important one is that we’re a health illiterate nation. Studies show that about one third of our population doesn’t understand the connection between their lifestyle and their health outcomes. Consumer-driven initiatives are predicated on the assumption that the consumer can understand the issue and take appropriate action to change behavior.
Are we doing enough? No. The government could pour all of its budget into patient education, but if the people don’t receive a message that they can understand and act upon, we’re wasting our time. The real challenge for consumer-directed initiatives is to deliver health literate, culturally competent messages that resonate with diverse populations. If I sent a bunch of posters to certain communities with a picture of the Surgeon General saying, “eat less and exercise more” would that change behaviors in that community? No. What we need to do is partner with community leaders, whether it be a priest or a rabbi or a grandmother or a block neighborhood captain – someone who has credibility in that community and work with them and spend the time necessary to change the culture.
The American public wants the best of everything, they want it yesterday, and they don’t want to pay for it. That pretty much characterizes the problem that we have. We see health as a right, we want somebody to give us a card, and if we want to smoke, that’s our right too. There’s this attitude that if we want to drink excessively, that’s our right, and if we want to ride a motorcycle without a helmet, that’s our right (“you can’t tell us what to do”). However, when I crash my motorcycle and I have a head injury and I’m disabled for life, I also expect society to pay for that.
We have to do a better job of improving health literacy so that American people of all socio-economic strata can understand the consequences of the choices that are deleterious to their health and help them to adopt appropriate behaviors that optimize health and wellness. Health literacy is the currency of success for everything we need to do to improve the health, safety, and security of our nation. It’s part of what we include in every project we do at Canyon Ranch Institute, with all our partners.
Dr. Val: And how do we get the message across to them, then?
Dr. Carmona: Boy, people have written books on that one. I’ve been plagued by this question, Val, ever since I came into the office of Surgeon General. I remember one day sitting down with my staff and taking a look at the previous Surgeon General reports. I thought they made pretty good book ends and looked nice in my office, but I wanted to know what we used them for. One staff member said, “Well sir, these have been developed to define the base of knowledge on a given topic and it helps our peers decide what needs to be done. It has a long bibliography and it’s based on science.”
But then other staff told me, “Really these are written for the public, so they’ll understand the information.”
And I thought to myself “I don’t know that any of the ‘public’ that I grew up with could read this.”
So I started a program to help communicate health messages to the American public. The goal was to develop resonant messages that would result in maximal behavior change over time. My advisors told me that the messages had to be written at a sixth grade level. So what we did with every Surgeon General’s Report and every Surgeon General’s Call to Action and other publication – we published the “Peoples’ Piece” to go along with it. It was full of pictures and written like a comic book to facilitate parent-child dialog about health. We also wrote them with cultural sensitivities in mind. The science behind our recommendations doesn’t change, but you have to send out thousands of messages to resonate with people from different cultures and languages – who are all Americans – in order to change their behaviors. So that’s what makes this so difficult.
Dr. Val: How do you get the ‘Peoples’ Piece’ to the people? Do you use the Internet or new media approaches?
Dr. Carmona: Unfortunately it’s often the case that the people who need the information the most don’t have Internet access. But the Internet can be incredibly powerful. For example, Dr. Francis Collins (the head of the human genome project at NIH) helped me with the U.S. Surgeon General’s Family History Initiative. We put our heads together to help people understand the significance of family health history.
We put it on the Internet and also distributed it to libraries, post offices, community centers, and schools. It helped people to create a family health tree to use as a talking point with their doctors. They could remind their doctors that, for example, their aunt and grandmother had breast cancer and then ask if they should be monitored more closely. Or they could discuss the fact that their uncles and cousins all had heart attacks before age 50. This tool helped people to begin identifying their risks based on a good family history – which busy docs don’t pay enough attention to anymore. When you know your history, genomics becomes valuable. If we can characterize disease, then we can search for potential genetic loci to help explain what’s going on and take a preventive approach to modifying the person’s environment to mitigate risk.
This concept is extraordinarily hard to communicate, but the Family History Initiative helped to make it accessible to people. We released the project at Thanksgiving time – when we knew that families would be together and could discuss their health histories, and it was a resounding success. Within a week or two we had hundreds and thousands of hits, with people asking for more information.
***
The Surgeon General series: see what else Dr. Carmona has to say about…
Cost Savings Associated with Preventive Health
Obesity is America’s #1 Health Concern
Complementary and Alternative Medicine
Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 23rd, 2008 by Dr. Val Jones in Expert Interviews, News
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Imagine that you were diagnosed with cancer, and were told that you had one of two treatment options: 1) you could receive a one time dose of a medicine that will go directly to the tumor cells and kill them only, having very few noticeable side effects or 2) you could undergo months of exposure to toxic chemicals that will kill the tumor cells and many other healthy cells as well, resulting in hair loss, bowel damage, nausea, and vomiting. Which would you choose?
Unfortunately, choice number one may no longer be an option for lymphoma patients due to government funding cutbacks, and the development of such treatments for other cancers is in jeopardy as well.
Radioimmunotherapy (RIT) is a relatively new approach to cancer treatment, new enough that the government is having difficulty categorizing it correctly. (RIT involves targeting cancer cells with special antibodies that carry tiny, lethal radiation doses to individual cells.) In fact, drugs like Bexxar and Zevalin have been misclassified by CMS as “supplies” rather than medications, and so the reimbursement allowed doesn’t come close to covering the cost of the therapy. Although there are many new targeted therapies under development, investors are worried that the drugs will never be used in patient care because the country’s number one payer (Medicare) is unwilling to cover their costs. Other health insurers often follow the government’s lead when it comes to treatment coverage policies. If no one will pay for the cost of the drug, then ultimately no one can afford to make it available.
Similar funding problems are beginning to limit access to diagnostic nuclear imaging modalities like PET scans, PET CT, cardiac SPECT scans, and bone scans. Reimbursement levels that do not cover the cost of the imaging drugs means that facilities cannot afford to offer these diagnostic technologies to patients, and centers are slowly reducing the number of tests they offer. Nuclear imaging studies are often critical in diagnosing heart problems, infections, and early detection of cancer. Senator Arlen Specter had his cancer recurrence diagnosed at the very earliest stages thanks to PET scanning technology. Early treatment offers him the best possible prognosis, but he is in a dwindling group of people who have access to this imaging modality.
I spoke with Dr. Peter Conti, professor of radiology at the University of Southern California, and former president of the Society of Nuclear Medicine, from Spain this week – as he is attending the 6th International Workshop for Nuclear Oncology, a lymphoma conference where the crisis in reimbursement for targeted cancer therapies is being discussed, along with exciting advances in treating patients with lymphoma. The two different RIT drugs (Bexxar and Zevalin) for non-Hodgkin’s lymphoma are in jeopardy of not being available to Medicare patients due to proposed cuts in reimbursement. Recent plans to cut payment for these drugs have been halted by a temporary moratorium from Senator Kennedy. Here’s what Dr. Conti had to say:
“Let’s face it, lymphoma is not as high profile as other cancers such as breast, colon, or prostate. However, we’ve found a fantastic treatment option for it, and there are implications for the more common cancers, but that treatment option is being denied to lymphoma patients because facilities cannot cover the costs of offering it. I’d like the entire cancer community to rise up in support of lymphoma patients so that Congress will tell Medicare to fix the funding problem. If this doesn’t happen, it’s only a matter of time until novel RIT treatments are no longer an option and we’ll be stuck in the dark ages of non-specific chemotherapy and radiation treatments that harm the good cells with the bad. Personalized, targeted therapy is the future – and we’re missing the opportunity to further develop these novel therapies due to budget cuts.”
I reached out to the current president of the Society of Nuclear Medicine, Dr. Alexander J. McEwan, for comment:
“Molecular imaging offers critical tools for the early detection, diagnosis and treatment of many life-threatening diseases, including cancer. SNM recommends that CMS establishes appropriate reimbursement for all forms of nuclear and molecular imaging and radioisotope therapies at levels that allow optimum access and improved outcomes for all patients.”
Denial of RIT to lymphoma patients may be the first sign of a new trend limiting the development of high tech therapeutic innovations. Will America’s research engine run out of gas before we figure out how to treat cancer without side effects? Should we buy one more tank to get us over the crest of the targeted therapy hill? This is a judgment call that affects all of us at a time of great need and limited resources. What’s your take?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
