Saving Money and Surviving the Healthcare Crisis

What Doctors and Healthcare Can Learn from Tom Brady, Bill Belichick, and the New England Patriots

2012-01-09T10:08:00.001-08:00

As the new year starts, I'm eager for a fresh start and working on improving myself both physically and emotionally. I'm also eager for the NFL playoffs and seeing how my favorite team, the New England Patriots, fares under the leadership of Coach Bill Belichick and quarterback Tom Brady. Doctors and health care can learn much from their examples.

Over the past decade, the New England Patriots have been dominant appearing in 40 percent of the Super Bowls played and winning 3 out of 4. Nothing prior to 2000, would have suggested this superior performance with playoff appearances only six times from 1985 to 2000 and two Super Bowl appears, both losses. Their new head coach Bill Belichick hired in 2000 had a losing record in his prior stint at Cleveland. Their current quarterback Tom Brady was drafted in the second to last round.

So what was their secret for success? Nothing particularly earth-shattering. It was and still is a relentless focus on continuous improvement by practicing deliberately and explicitly. This is an important learning for the US healthcare system which consistently lags that of other industrialized countries when measured on quality outcomes.

In general, doctors don't focus on how medical care is delivered. We don't focus on our own continuous improvement, which is a far different philosophy than individual athletes in professional sports. In our profession and in our training, we also typically don't focus on ensuring that the care we provide is consistently reliable over a period of time with our diverse medical team.

Yet, success in the NFL is based on whether a group of individuals, which composition may differ annually, can execute the plan well every time.

For the team to do well, it first relies on the individual player to do well. Take the Patriots' quarterback Tom Brady. He is currently among the best quarterbacks in the NFL playing today. Some argue he may be the best ever to play the position. Was he destined for greatness early in his career?

No. In fact, Brady doubted his abilities early on while at Michigan. Change started to occur when he adopted a different mindset presented by one of his mentors, Michigan associate athletic director Greg Harden. It isn't about just talent that will result in success, but in fact a focus on improving one's skills which allow the possibility to be the best. Though he did succeed at Michigan, Brady was drafted in 199th by the Patriots in 2000.

What did he do? The future hall of famer simply did what he learned at Michigan - learn the position better than anyone else and be deliberate about his practice. His NFL rookie year was unremarkable. In the following year, as a second year quarterback, he started off slowly. He steadily improved to the point that when the Patriots were in the Super Bowl, he led the team to a final winning drive. Brady became the youngest quarterback ever to win a Super Bowl.

Despite reaching the pinnacle of a football career in January 2002, he hasn't stopped improving his skills. When asked recently to impart some wisdom to NFL quarterback rookie and Heisman trophy winner Cam Newton, Brady said this –

You always realize that you can always be better. You can always be a better friend, a better player, a better teammate, and always try to find ways to improve. I go out there and be the best teammate I can be; because the goal in life is to win.

Yet how often do doctors work specifically on themselves and improve what they truly control, that is their own individual skills and talents? How often do we each work hard on improving our clinical acumen, communication skills, surgical techniques, or diagnostic skills? As doctors after we have finished our advanced training via a residency or fellowship program, we don't seek opportunities to improve skills we believe we have mastered. In fact, we bristle at continuous improvement as New Yorker writer and surgeon Dr. Atul Gawande notes in his article Personal Best.

Nearly every élite tennis player in the world [has a coach]. Professional athletes use coaches to make sure they are as good as they can be.

But doctors don’t. I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?

Gawande tries an experiment and convinces a mentor, who he respects highly, to observe him in the operating room. Gawade reflected that in the debriefing with his mentor

That one twenty-minute discussion gave me more to consider and work on than I’d had in the past five years. It had been strange and more than a little awkward having to explain to the surgical team why Osteen was spending the morning with us. “He’s here to coach me,” I’d said. Yet the stranger thing, it occurred to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one’s sights. I’d had no outside ears and eyes.

Gawande observes that in health care

...the capabilities of doctors matter every bit as much as the technology. This is true of all professions. What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities.

So individually, each doctor can and should focus on improving his individual abilities and to know his position the best, to be a doctor's doctor.

But there is more. Health care isn't just about one position, one profession, or one doctor. Providing complex medical care is like leading a football team of 53 players of which only 11 are on the field at any given time to play offense, defense, or special teams. For success, each individual must do his job consistently and reliably every time. Anything short of that is incredibly obvious. Failings unfold weekly to tens of thousands of fans in the stadium and millions watching via instant replay, the internet, and ESPN. Success and failure is dictated by a win-loss record until the season ends and the cycle repeats itself.

The Patriots have been exceptional in the past decade not only because of having Tom Brady but also for the many other individual players who are focused not only on making their own skills better but to do so for the benefit of the team. Previous "troublemakers" and prima donna wide receivers Randy Moss and Chad Ochocinco, when joining the Patriots have been quiet, humble, hard-working, and focused on improving and contributing to the team. This team focus comes directly from the top with head coach Bill Belichick. Profiled recently by NFL films, note how he leads and prepares his team deliberately to think ahead, anticipate problems, and execute the plan consistently in practice. Though each player is a paid professional and should know the game instinctively, Belichick takes no chances. He says the following to players in practice -

I want to call out the situation, pay attention.
I don't care whether you are part of it or not.
First and ten, plus 50, alert for what.
Ok, they have no time outs. The ball is on the one yard line. Tell me what is going to happen here.
We got 40 seconds and need a field goal, two minutes.

We good on every thing fellas? No questions? We're good?

(confiding to his son) - Those situations are just as good for the coaches as they are for the players. Makes everybody think about what I might want to call here.

Like [Tom] Brady he's thinking one thing, Billy (Patriots' quarterback coach) is thinking something. We want them both thinking the same thing you know.

The win-loss record as well as playoff appearances, conference championships, and Super Bowl wins are consistent with high performance outcomes. Impressive considering that every other team in the NFL has players and coaches each driven to excel. What might healthcare learn from the Patriots head coach?

Can doctors and staff work together and regularly drill on scenarios both likely and rare? Can we use checklists and protocols and modify accordingly much the same way a coach changes the playbook? In medicine, we assume that that everyone knows his task when it comes to code blues and emergency surgeries. We also assume that everyone knows his task when it comes to mundane stuff like drawing up medications or discontinuing orders in the hospital. We are then stunned when adult heparin is given to babies in the ICU and the blood thinner coumadin isn't stopped when a resident doctors is interrupted with a text message with significant consequences to the patient.

We often blame the individual rather than ask can it be about something else that increases likelihood for success?

We don't fully appreciate the discipline or the processes needed to create a highly reliable organization. What we don't have are physician leaders who can take the care we provide to the next level. Note the comments from Dr. Thomas Lee, network president of Partners HealthCare System and professor of medicine at Harvard Medical School in a podcast regarding his article in Harvard Business Review - Turning Doctors Into Leaders.

[Doctors are] taught to rely solely upon themselves. They don't necessarily work well in teams. They don't think about the bigger picture, because they've been taught to focus just on the patient in front of them.

...to respond to the pressures created by all this [medical progress which causes rising costs, quality challenges, and chaos that patients experience] is for providers to get more organized and adopt systems that will bring order to the chaos. But that takes leadership. It takes the kind of leadership where you can persuade clinicians to work together in teams, as in almost every successful business, they already do.

For the US healthcare system to improve and succeed in providing highly reliable and safe care to everyone, it will require individual doctors to be like Tom Brady and ask - is there something I can do even better? It will require some doctors to be like Bill Belichick and ask - is there a process and discipline I can provide to allow the team that I lead succeed?

Doctors can and must lead the changes that everyone in the country wants from our health care system. There is no other group best suited to the task.

The question is - are doctors ready to step up?

Go Pats!

White Coke Cans and the Importance of Visual Cues in Reducing Medical Errors

2011-12-02T05:57:00.001-08:00

I read with some amused interest that many consumers were upset that Coca Cola had updated their traditional red regular Coke can for a holiday themed one complete with white packaging. The new holiday design was felt to be too similar to the diet Coke, which is silver. Although Coke has released festive appearing Coke cans in the past, this design was devoid of significant elements of red which make it stand out from the silver Diet Coke packaging. This year Coke felt a bold design would highlight their association with the World Wild Fund and saving the polar bear.

As a result, Diet Coke drinkers not realizing the switch would find themselves gulping the sugary regular Coke, an absolute no-no. Outraged, they took their concerns up on the internet. Coke has decided to take the new white Coke can off the market and replace it with the traditional red Coke can sooner than planned.

But what does this have to do with medical errors?

Plenty.

Doctors and nurses often work in a world devoid of visual cues where the stakes are much higher than sipping the wrong type of cola. Ironically, doctors and nurses when they makes these errors, they blame themselves and not the package design for some of the error. Even the public

Case in point?

About four years ago, actor Dennis Quaid's newborn twins nearly died from a drug overdose of the blood thinner heparin while hospitalized at the prestigious Cedars Sinai medical center. The babies were given the adult dosage of heparin which was 1000 times greater than that for a baby. Their blood essentially was water and coming out of every orifice.

Part of the reason for the error? The packaging of the vials for adult and pediatric heparin is nearly identical.

Do they look identical to you? A busy nurse used to routine perhaps gets a heparin dose which by design looks similar but not exactly the same mistakenly draws up the dose because it looks similar but not difference enough to jostle her conscious memory that there is a problem here. This is part of human nature and using mental shortcuts subconsciously. Looking at it now with your full attention it seems obvious.
Even the public and health care personnel often attributed the error to the individual rather than the design packaging when reviewing some of the public comments related to the story.

Why is Baxter being sued for the hospital having stupid nurses who can’t read?… Shame on Dennis Quaid and shame on the Cedars Sinai for retaining a moron of a nurse.

As a nurse, the reality is that the NURSE DID NOT READ THE LABEL before admninstering the drug. Nurse are taught to take a minute and look over the drug that are about to give. Is it the right route, the right dose, the right drug and is it the right patient. We are taught to not check one but twice or three times. Besides heparin there are many different drugs pachaged the same way. You would have to change every single drug packaging to prevent errors. The reality is the nurse DID NOT perform the 4 checks she was suppose to! That is not the fault of the pharmaceutical company.

But in an intensive care unit where you normally work everyday and where you never had had an error and you mistakenly draw up a medication 1000 times too potent because the packaging looked similar enough that your brain didn't see a problem? You didn't realize that somehow the high dosed medication made it to your hand.

Kind of the same way many diet Coke drinkers didn't realize a higher calorie content soda reached their hand and in their mouth as they went about their routine daily lives.

Unlike doctors and nurses, however, the public rightly didn't blame themselves. The package design contributed to their error. It is about time that our health care providers do the same and work on fixing the system we work in rather that often simply concluding it is the fault of the individual.

As for me, I think I'll pick up some white Coke cans for the holidays. They are kind of cute!

Your Medical Mind - Book Review. Best for Patients or Doctors?

2011-10-11T05:48:00.000-07:00

I looked forward to reading Dr. Jerome Groopman’s new book, Your Medical Mind – How to Decide What is Right For You, co-authored with Dr. Pamela Hartzband. His previous work, How Doctors Think, shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions. I always recommend my medical students read that book.

Unfortunately, his latest work fell quite short of my expectations. In it, the authors try to understand and create a framework on how patients reach decisions about their medical care. In the end, this was a book about human psychology wrapped in the doctor patient relationship. Nothing particularly earth shattering here.

The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors? Patients or doctors?

They note how the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.” Specifically, some patients want maximal treatment and others believe “less is more”. To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms. Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.

Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions. Finding a doctor who provides “shared medical decision making” might also decrease the chance of making a choice only to regret it later. In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament. Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference. There is both power and potential pitfall in hearing other patient’s stories, which may be anecdotal.

Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance. Sometimes patients want full control. Other times they wish to cede it to physicians, hence the reason many want to find the “best” physician. Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use “substituted judgment” and choose treatment based on what the patient would have wanted. Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation. As a result, sometimes doctors use the principles of “beneficence”, the principle that physicians should act in the patient’s best interest, and “nonmaleficence”, to do no harm.

Physicians can also unwittingly bias a patient’s decision by recommending a “best” treatment and downplaying others, which could be a better match for the patient’s preference. Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient. These seems rather ludicrous as already many current guidelines are not being followed.

The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don’t simply rubberstamp what you want. “A doctor who facilitates but also may challenge your decision process sometimes gives you more.”

Completely agree. Perhaps this book is best suited for doctors. While the book may be an enlightening read for patients, there isn’t necessarily an easy practical framework which will help them make the right decisions.

Do Computers Really Come Between Doctors and Patients? Is the Future Here?

2011-09-09T00:20:00.000-07:00

One of my favorite movies is Back to the Future starring Michael J. Fox. I must admit after reading this New York Times piece, titled "When Computers Come Between Doctors and Patients" I have to wonder.

Am I fortunate to be coming from the future? Because I completely disagree with Dr. Danielle Ofri, again.

I've had the privilege and opportunity to work in a medical group which has deployed the world's largest civilian electronic medical record and have been using it since the spring of 2006. I don't see the issue quite as much as Dr. Ofri did. It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can google any image instantly? Patient friendly information to reinforce our discussion is a click away.

The computer can certainly enhance the doctor patient visit. Like any skill, unless we deliberately practice in getting better, we will simply find the new method awkward and unnatural.

And the same goes for emailing patients securely. An October 2010 article in Pediatrics found that for a 127 families only 5 emails were generated compared to over 2300 phone calls over an 8 month period. The data doesn't lie.

The conclusion of the article was that -

Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.

So doctors could conclude that patients really don't want to email their doctor. What a relief because the majority of patients still do not have the option to do so and doctors don't really want to do it. (Though there could be compelling business reasons not to offer email to patients even if the doctors were technically savvy enough to offer it).

But yet this earlier press release in July 2010 may cause doctors to pause before returning to paper charts, pens, and phones. This study found that over a two month period, 35,000 patients generated 556,000 email threads.

So what does this all mean? As doctors we need to change our mindset and look at these changes as opportunities for the medical field to provide care that is increasingly worry-free, hassle-free, and personalized.

The future is here. That means embracing the computer.

None of my patients would ever go back.

Neither would I.

Speaking of Back to the Future, I understand a limited supply of Marty McFly's shoes are now available for purchase! Bids are at $4000!

A Doctor Thanks His Mentor - Steve Jobs

2011-09-05T15:15:00.000-07:00

I've been reading A Game Plan for Life: The Power of Mentoring written by famed UCLA basketball coach John Wooden. Wooden spends half of his book thanking the people who had a powerful influence on his life, coaching, philosophy, and outlook on life. Important people included his father, coaches, President Abraham Lincoln, and Mother Theresa.

Yes, President Abraham Lincoln and Mother Theresa.

Though clearly he could have never met the former and didn't have the opportunity to meet the latter, Wooden correctly points out that as individuals we can be mentored by the writings, words, and thoughts of people we have never and will likely never meet.

Which seems like the most opportune time to thank one of my mentors, founder and former CEO of Apple, Steve Jobs.

Now, I have never met nor will I ever meet Steve Jobs. Lest you think I'm a devoted Apple fan, I never bought anything from Apple until the spring of 2010. Their products though beautifully designed were always too expensive. I'm just a little too frugal. I know technology well enough that people mistaken me for actually knowing what to do when a computer freezes or crashes. Yet, the value proposition was never compelling enough until the release of the first generation iPad. Then the iPhone 4. Finally the Macbook Air last Christmas.

No, thanking Steve Jobs isn't about the amazing magical products that have changed my life as well as millions of others. It's more than that. What he has mentored me on is vision, perspective, persistence, and leadership. Nowhere is this more important than the world I operate in, the world of medicine. Increasingly health care is fragmented, confusing, and frustrating for patients. As Dr. Atul Gawande noted in his commencement to Harvard Medical School:

Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.

We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people.

We don't have an actual system of care. A majority of doctors still use paper charts and prescription pads which can be difficult to access or decipher (doctors have poor penmanship?) and communicate with colleagues via letters, faxes, and phone calls. In an industry which is information driven, this seems too antiquated to be true. Hospitals each have their own unique system of care and their is little standardization which means both patients and doctors need to learn new rules with each new hospital. Patients cannot invest in long term relationships with their doctors because they change jobs, their company or their doctors dropped their previous insurance plan.

What we have is a potpourri of doctors, hospitals, pharmacies, and health insurers cobbled together to form a "health care system". For a patient, the number of combinations is staggering. Each experience varies depending on who they see, what insurance coverage they have, and the type of (or lack of) information technology their doctors have. Many doctors today still bristle at the possibility that they actually need to email their patients and as a result don't offer that as a way of communication or education.

In the end, what patients and doctors really want sits at the intersection of humanity and technology. Patients want doctors who know them as individuals, use medical technology thoughtfully, and a system that is highly reliable, safe, and focused on them to stay well or get them better. Doctors want patients who are partners in their care, technology that enables them to get the accurate information they need real-time, and a system that is streamlined to allow doctors to be healers.

In other words, we need a better health care system for both parties.

As a practicing primary care doctor, his words inspire me to help work towards creating a system which "simply works" for both doctors and patients. Some of the most important quotes that has shaped my thinking include:

“Innovation has nothing to do with how many R&D dollars you have. When Apple came up with the Mac, IBM was spending at least 100 times more on R&D. It’s not about money. It’s about the people you have, how you’re led, and how much you get it.” — Fortune, Nov. 9, 1998

“It’s really hard to design products by focus groups. A lot of times, people don’t know what they want until you show it to them.” — BusinessWeek, May 25 1998

“It comes from saying no to 1,000 things to make sure we don’t get on the wrong track or try to do too much.” — BusinessWeek Online, Oct. 12, 2004

“Do you want to spend the rest of your life selling sugared water or do you want a chance to change the world?”
— The line he used to lure John Sculley as Apple’s CEO, according to Odyssey: Pepsi to Apple, by John Sculley and John Byrne

"So you can't go out and ask people, you know, what the next big [thing.] There's a great quote by Henry Ford, right? He said, 'If I'd have asked my customers what they wanted, they would have told me "A faster horse." ' " -- CNN / Money

"My job is to not be easy on people. My job is to make them better. My job is to pull things together from different parts of the company and clear the ways and get the resources for the key projects. And to take these great people we have and to push them and make them even better, coming up with more aggressive visions of how it could be." -- CNN / Money

"Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary." -- Stanford 2005 commencement address

Many of my blog posts have reflected on whether health care can indeed be better than it currently exists much the same way Jobs has redefined how we as a society communicate, relate, receive, and create content.

Does America Want Apple or Android for Health Care?

What Steve Jobs and iPhone 4 Antennagate can Teach Doctors and Patients

Why Healthcare Needs to be More Like Apple and Less Like Windows / Intel

I as a doctor I'm incredibly sorry that medicine has not yet evolved to the point that a cure exists for the rare type of cancer Jobs. I'm sorry that he is so ill at an incredibly young age, in his mid 50s, when many people begin to contribute even more to society with all of the knowledge and experience they've acquired. The future might be a little less bright without Jobs leading his team at Apple on creating products and experiences none of us truly knew existed until he showed them to us.

And yet, I wanted to thank him for his mentoring. Clearly though the outpouring of comments and support across the web, Steve Jobs has had a profound influence in many of our lives. In most cases, it wasn't even about the products.

It was simply a way of living and viewing life.

I look forward to learning one last time from my mentor this fall with the release of his book titled Steve Jobs.

My thoughts are with him, his family, and the people at Apple who continue to innovate and challenge themselves so the rest of us benefit.

NY Times - Finding a Quality Doctor - Why the Author and Doctors Are Wrong.

2011-08-21T14:32:00.000-07:00

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following - 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren't what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor's bedside manner, should count as well.

Her article was simply to illustrate that "most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care" yet when she offered this perspective, a contrary point of view, many viewed it as "evidence of arrogance."

She comforted herself by noting that those who criticized her were "mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care."

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card -

I don't even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It's too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I'm afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can't do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren't in the office and yet are suffering.

Until we as doctors begin to take responsibility for our performance in hard clinical and objective outcomes like glycated hemoglobin levels, cholesterol, and blood pressure, our patients will pay a price. We should not pretend that bedside manner should trump clinical outcomes nor that clinical outcomes should override the humanistic part of medicine.

It is possible to do both today. It isn't theoretical. I only serve as one example.

I'm a front-line primary care doctor who also takes care of patients. I like Dr. Ofri also get a report card on my performance in caring for patients with diabetes.

Based on the medical evidence, my goals are set similarly to hers. For 2010, my performance wasn’t perfect but was 88.6%, 80.8%, and 70% at goal respectively.

I suspect critics will immediately begin to make a lot of assumptions of how these scores were achieved, when Dr. Ofri, another primary care doctor had very different outcomes. Is it that I am not a quality doctor? Perhaps I’m too driven by data and have no - “soft” attributes like attentiveness, curiosity, compassion, diligence, connection and communication. Perhaps I "fire" those patients who are not able to achieve good outcomes.

I can tell you many patients wish to join my practice and rarely do people choose to leave it. The organization I work for also takes the softer side of medicine, a doctor’s bedside manner, seriously. My employer randomly surveys patients on their experience. Does your doctor listen and explain? Do they know your medical history? Do they partner with you in your health? Do you have confidence in the care they provided you?

For 2010, 92.8 percent rated me very good or excellent on these elements.

So what does this all mean?

We should not automatically assume that doctors with great bedside manner cannot also provide great clinical care.

I can achieve the goals, which patients would want, and still be a doctor with great bedside manner because I work in a functional system like Kaiser Permanente. Primary care doctors are blessed with a comprehensive electronic medical record, are partnered with staff who help patients get the care they need, and are surrounded by specialty colleagues equally as focused to keep patients healthy and well.

So if there is any area of agreement with Dr. Ofri it is that simply giving doctors report cards and telling them to try harder will simply achieve mediocre outcomes. Until there is a fundamental restructuring on health care is delivered (and simply making appointments longer isn't necessarily going to solve it either), then primary care doctors will continue to leave the specialty in droves. Doctors need to lead change and use tools and skills honed in other industries, whether the Toyota Production model or lean process, which has been utilized by the Virginia Mason Hospital, or usage of protocols and checklists based on scientific evidence as demonstrated by Intermountain Healthcare and Dr. Brent James.

Until we as doctors lead, we cannot or should not expect improvement in patient outcomes. We can no longer hide behind the reasons of our Herculean effort or bedside manner as what should really matter and account for something. Patients expect these attributes intuitively.

With already so many examples of success in the country marrying the art, science, and humanistic part of medicine, the only thing stopping us to re-invent American medicine in the 21st century is simply ourselves.

Newsweek - Just Say No! - One Word Can Save Your Life. Too Simplistic. Doctors Need to Help.

2011-08-15T16:20:00.000-07:00

Newsweek has a very provocative and yet incredibly too simplistic piece for the public and patients on its cover story - One Word Can Save Your Life: No! - New research shows how some common tests and procedures aren’t just expensive, but can do more harm than good.

The piece is actually well written and highlights facts that have been apparent for some time. More intervention and treatment isn't necessarily better. Having a cardiac catheterization or open heart surgery for patients with stable heart disease and mild chest pain isn't better than diet, exercise, and the prescription medication treatment. PSA, the blood test previously suggested by many professional organizations, isn't helpful to screen for prostate cancer, even though the value of the test was questioned years ago. Antibiotics for sinus infection? Usually not helpful.

Certainly doctors do bear part of the blame. If patients are getting routine colonoscopies sooner than every 10 years or are getting them despite being quite a bit older (80 and older) and frail, then clearly patients should say no to more care. More isn't better. (Whether a patient has the conviction to do so is another story. When my auto mechanic says it is time to change the brakes or change the oil, who am I to say no?)

But the overtreatment and overuse of medical technology does not just fall on the doctors. It is also the patients' and the public's perception of what is the right care. Whether this perception was shaped by doctors, the media, movies and television shows, or patients comparing notes is hard to say, but the reality is patients have a certain expectation of what should be done which often is in stark contrast to the right thing to do. For low back pain, many patients simply want a MRI and avoid an examination or visit. After all, isn't the truth in the MRI? Isn't talking to a patient and examining his back, knee and ankle reflexes, evaluating for joint strength and sensation simply from a by-gone era that is antiquated in the 21st century? Do patients know the limitations of our understanding not in the history or physical examination honed by generations of doctors before us, but the shiny new piece of technology rolled out annually by General Electric? As Dr. Michael Lauer, a cardiologist of the National Heart, Lung, and Blood Institute noted in the piece, “Our imaging and diagnostic tests are so good, we can see things we couldn’t see before...But our ability to understand what we’re seeing and to know if we should intervene hasn’t kept up.”

Doctors who do provide the right care, which often is low tech and common sense, might be viewed as denying care. If a patient has chest pain which is easily treated with a statin (cholesterol lowering) drug and beta-blocker and a cardiologist is not needed for further intervention, do you think the patient or the family will feel more relieved or more anxious? If a stress test isn't offered to an otherwise healthy middle aged man as part of a physical (or at a minimum an EKG) and yet is offered the identical tests as part of an executive physical, do you think the public at large will feel better or worse in not having the tests, which are correctly noted in the article not proven to save lives? (It is ironic that although fantastic experts are quoted in the piece including Dr. Steven Nissen, a cardiologist at Cleveland Clinic, his organization offers executive physicals, which you guessed it provide many of these tests and interventions to paying clients. Though the results of the majority of the tests are normal it is that remote possibility that something might be wrong and the basis of the testimonials on the website that have the public clamoring for more testing and treatments).

In today's society where news is disseminated as sound bites or tweets, I am concerned about the unintended implications this Newsweek story will bring: patients will say no to everything. Based on a well written, though not entirely balanced article, patients will anchor their decisions to default to no based on this small piece of information. It has already occurred with vaccinations. As the National Committee for Quality Assurance noted in its 2010 State of Health Care Quality report, childhood immunization rates for those in private insurance has actually fallen compared to those in public insurance (Medicaid) plans.

Childhood vaccination rates in 2009 declined by almost four percentage points in commercial plans.   A possible cause of this drop is commercial plan parents may refuse vaccines for their children based on the unproven, but increasingly popular, notion that vaccines cause autism. Celebrity activists are outspoken advocates of this view. Interestingly, we see vaccination rates in Medicaid – the program serving the poor – continuing to steadily improve.

“The drop in childhood vaccinations is disturbing because parents are rejecting valuable treatment based on misinformation,” said NCQA President Margaret E. O’Kane. “All of us in health care need to work together to get better information to the public.”
The State of Health Care Quality Report examined quality data from over 1,000 health plans that collectively cover 118 million Americans.

Because of the complexity, nuances, and ever changing nature of medicine, patients more than ever need doctors to lead and be firm on what works and what does not. The anecdotal quote by a doctor who opted not to have a mammogram should be taken as one person's opinion and not a recommendation for all women to do the same. Having patients say no or expecting them to make the right decisions for themselves and family is not how the country will get better care. A recent NY Times piece by Dr. Pauline Chen titled Letting Doctors Make Tough Decisions could not have been more timely.

... a new study reveals that too much physician restraint may not be all that good for the patient — and perhaps may even be unethical. While doctors might equate letting patients make their own decisions with respect, a large number of patients don’t see it that way. In fact, it appears that a majority of patients are being left to make decisions that they never wanted to in the first place….

The challenges appear to arise not when the medical choices are obvious, but when the best option for a patient is uncertain. In these situations, when doctors pass the burden of decision-making to a patient or family, it can exacerbate an already stressful situation. “If a physician with all of his or her clinical experience is feeling that much uncertainty,” Dr. Curlin said, “imagine what kind of serious anxiety and confusion the patient and family may be feeling.”

Medical choices are not as obvious. Today the vast amount of information and choices are overwhelming. The easy and natural thing to do is to run away or bury our heads in the sand, or simply say no when decisions are complex.

The Newsweek article concludes -

Many doctors don’t seem to be getting the message about useless and harmful health care. Medicare pays them more than $100 million a year for screening colonoscopies; some 40 percent are for people in whom they will almost certainly harm more than help. Arthroscopic knee surgery for osteoarthritis is performed about 650,000 times a year; studies show that it, too, is no more effective than placebo treatment, yet taxpayers and private insurers pay for it. And although several large studies, including the Occluded Artery Trial in 2006, have shown that inserting a stent to prop open a blocked artery more than 24 hours after a heart attack does not improve survival rates or reduce the risk of another coronary compared with drugs alone, the practice continues at a rate of 100,000 such procedures a year, estimate researchers led by Dr. Judith Hochman, a cardiologist at New York University. “We’re killing more people than we’re saving with these procedures,” says UT’s Goodwin. “It’s as simple as that.”

Actually, I think doctors are getting the message as Dr. Atul Gawande noted in the June 2009, New Yorker piece Cost Conundrum. Doctors are compensated more to do more. Even medical students get the message. Increasingly more are becoming specialists as reimbursement is far more lucrative in doing procedures than it is to simply talk and counsel patients.

The Newsweek piece tries to simplify the problem too easily by hinting to patients that saying no is a good thing rather than challenging patients to have an open-minded, important and thoughtful conversation about the advantages and disadvantages of having certain tests or treatments with their primary care doctor. Of course since fewer medical students want to do primary care, my job and those of my colleagues in family medicine and internal medicine just got a lot harder.

Are Patients Becoming Day Traders?

2011-07-27T07:39:00.000-07:00

Let me say first that I am a practicing primary care doctor who is very much focused on patient centered care. Though I cannot go back to being a patient who is unaware about what a doctor does, the terminology she uses, or what the importance of certain test results are, I can empathize with the overwhelming amounts of information, challenges, and stressors patients and families can have in navigating the healthcare system to get the right care. This is the reason I wrote my book.

However, over the past few months I've noticed a particularly disturbing trend. Patients are not consulting doctors for advice, but rather demanding testing for diagnoses which are not even remote possibilities. A little knowledge can be dangerous particularly in the context of little to no clinical experience. Where many patients are today are where medical students are at the end of their second year - lots of book knowledge but little to no real world experience.

More patients are becoming the day traders of the dot.com boom. Everyone has a hot stock tip, only now it is "be sure to ask your doctor for this test" or "ask for this medication because it is the only one that works". Everyone is an expert with his own suggestion on what should be done. If a medical expert, like a doctor, weighs in and does not agree, then there is a set of patients and doctors who begin to argue that these doctors are out of touch or arrogant.

Hardly.

I certainly agree that many doctors frown upon their patients doing research online. I disagree with my colleagues. I'm all for patients being partners in their health as long as when they research they also go to reputable websites, like the Mayo Clinic or Kaiser Permanente, and also give equal weight to my medical advice. Ultimately, patients should be more knowledgeable about their health and engage not only with doctors, but with family and friends as health does not begin with doctors, but in households and communities. However, today's world is increasingly polarized due to the ability to gather information and find opinions of like minded people quickly and easily. A patient researching information can unwittingly blind themselves into believing that a medication, a treatment, a test, or a diagnosis is the only one that explains their symptoms.

Many of the patients who Google their symptoms, do cursory research, and are so convinced that they have a particular problem and need a particular solution are the group I worry about the most. They want to see a specialist for a problem adequately handled in primary care. They want a branded medication when a generic medication works equally as well. They want CT scans and MRIs for migraine headaches or sprained ankles when a generation ago, doctors and patients believed diagnoses based on common sense. They decline vaccinations for preventable illnesses like pertussis, whooping cough, because they are healthy and don't want "chemicals" even though the state they live in had the worst outbreak of pertussis since 1955.

With more Americans paying for their health insurance through higher copays for doctor visits, medications, imaging, and treatment, it is understandable that they want more information and are seeking it. What is particularly troubling, however, is much like the day traders of years ago, many are bypassing experts for some advice and consultation. Indeed a decade ago many ridiculed financial guru Warren Buffet for failing to understanding the new world and being a dinosaur. Principles of the past no longer applied. (Of course, financials principles remained - you do need to make money to be an ongoing company). As a front line doctor, I'm seeing the same phenomenon in health care. Doctors still clinch the right diagnoses by talking to and then examining patients. Skipping directly to lab work or imaging often gets the wrong answer. Sometimes there is no test or imaging study that can get the diagnosis. Yet somehow if asked, patients retort I don't have money to see you, I'd rather spend the money on the test or medication, so can you order it?

Like the day traders of a decade ago, these individuals have the illusion of control or mastery. Only later do they discover when the results are normal and the problem remains that being an expert and having the ability to take in information, process it, and then come up with a plan is harder than it looks. (Dr. Lisa Sanders, whose New York Times series Diagnosis was the inspiration for the television show House, M.D., has excellent patient cases which challenge the public on getting the right diagnosis).

That is not to say that there are not patients who are indeed experts. The individuals who are leading the empowered patient movement often know a lot about their diagnoses and treatment options and have mutual respect from their doctors. Enlightened doctors realize that they cannot know it all. I would hope and believe that empowered patients also recognize this inherent problem in themselves as they also cannot know it all either. It is the rich discussion and collaboration which occurs when both groups are on relatively equal footing in terms of knowledge that the answers, solutions, and treatment plans are far better than if only one side or the other led the conversation. Those patient experts probably can and have identified their condition when they read it in Dr. Sander's column.

Who would have guessed that the day traders of the past would now appear as patients? Funny and sad how history repeats itself. The difference is unlike money the stakes are significantly higher when it comes to health.

Not sure what to do when you have a problem? It's ok to research online, but then have an open mind when talking to your doctor. If your doctor does not want to listen, then find another one. Be sure, however, as you research and listen, that you do not become a day trader. Indeed, if not done correctly the consumer driven health care movement has the potential to be equally as problematic as the retirement planning and investing movement a decade ago.

Required Reading for Medical Students, Interns, and Residents.

2011-07-05T06:56:00.000-07:00

I have had the privilege of working at an organization which is actively improving the lives of its members and also was mentioned by the President as a model for the nation. Over the past few years, I have also demonstrated to first year medical students what 21st century primary care should look and feel like - a fully comprehensive medical record, secure email to patients, support from specialists, and assistance from chronic conditions staff.

But as my students know, there are also some suggested reading assignments. I'm not talking about Harrison's or other more traditional textbooks related to medical education. If the United States is to have a viable and functioning health care system, then it will need every single physician to be engaged and involved. I'm not just helping train the next group of doctors (and hopefully primary care doctors), but the next generation of physician leaders.

Here are the books listed in order of recommended reading, from easiest to most difficult. Combined these books offer an understanding the complexity of the problem, the importance of language in diagnosing a patient, the mindset that we can do better, and the solution to fixing the health care system.

Which additional books or articles do you think current and future doctors should know?

Overtreated - Why Too Much Medicine Is Making Us Sicker and Poorer
Balanced and thoroughly researched, this book illustrates how the failings of our healthcare system are more complex than simply claiming that insurers are greedy and malpractice insurance premiums are too expensive.

Patients with the same illness are getting more costly medical care in certain parts of the country but actually do worse. The amount of medical care delivered is driven by the number of specialists, hospitals, and technology available in the community. The more doctors and hospitals add new services and technology the more likely those expensive services are used regardless of whether patients need it but because the providers can get paid for it. When organizations and committees try to set up guidelines or do research to see if current therapies are effective, special interests and politics kill the initiatives.

Hospitals focus on generating more business in departments which are profitable, like oncology, with newer buildings and the latest medical equipment so that they can afford to run emergency departments which continually lose money. Doctors and patients are enamored with the latest treatments and interventions which often are far more expensive, aren't better than existing therapies, and like the case of bone marrow transplant for metastatic breast cancer patients, are more lethal.

The pharmaceutical industry is intimately linked to doctor education and invariably influences which prescriptions are prescribed and market prescription medications as easily as consumer companies promote common household products. It is money not science that drives the healthcare system.

The author believes that solving the dysfunctional healthcare system requires that doctors and hospitals align themselves into integrated healthcare organizations like the Mayo Clinic, Kaiser Permanente, and the Veterans Health Administration. Unfortunately, however, because she makes such a compelling case of how each of the various providers and businesses each have a financial self interest to keep the current system going at the detriment of patient care, it is difficult to see how the transition will occur, if ever.

How Doctors Think
Fascinating read and written in the same spirit as Malcolm Gladwell's Blink. Dr. Groopman investigates how doctors make misjudgments and misdiagnoses because of their failures to understand and acknowledge cognitive limitations and errors in thought that affect all of us and are unbeknownst to us. He feels that if doctors take a step back, are introspective and insightful about these deficiencies and take appropriate steps to minimize these problems, we can be better clinicians. The doctors he profiles are truly inspirational, remarkable, and masters in their fields, not only because of their medical knowledge, but because of their recognition of what it takes to be superb people and clinicians.

If there is an area of disagreement, then it is the fact that Dr. Jerome Groopman suggests that the pressures of managed care and inadequate time are the cause of many of these cognitive errors. Yet, he never actually proved this in the book. He never showed that doctors were more likely to make the correct diagnoses in an era with fewer time constraints. In fact, he laments that doctors in training, where he teaches at Harvard, don't know how to think and then realized that he hadn't be trained how to think either over thirty years earlier (and hence the reason for his investigation and this book). He claims that quality of medical care shouldn't be simply defined as whether or not a patient with diabetes has his blood sugar checked routinely, yet Dr. Groopman also doesn't acknowledge that the major reason the United States ranks last in the world in keeping people healthy is because the quality of care delivered never was measured as carefully as it is today. Research shows that 80,000 Americans die prematurely (twice the number of breast cancer deaths) simply because the right preventive care wasn't delivered. Had the nation adopted those health insurance plans, hospitals, and doctors, who performed at the top 10 percent of providing this care, these individuals would be alive today. How do they do so well? It is because of implementation of systems that promote excellence.

As a practicing primary care doctor I understand the concerns of my colleagues of showing and proving that they are doing what they say. But we all know if you don't measure something and then re-evaluate it, how do you know if you are doing better? If anything, Dr. Groopman seems to suggest that medical care would be better if doctors didn't have to prove that they performed these metrics to the level of what the evidence shows to be effective even though other industries like financial services, manufacturing, and the airline industry do so rigorously to maintain their high levels of reliability, consistency, and safety.

Although he encourages patients be advocates for themselves, to ask questions, and how to slow a doctor down and think more clearly with certain comments, from his own examples it is clear that it isn't easy to do and frankly somewhat intimidating.

If there is a lesson to be learned, then it is that as doctors we need to understand that our thought processes can be clouded by emotions and can be limited simply because we too are human. To overcome this problem, which affects all of us, we need to be deliberately thoughtful and systematically introspective when caring for patients. As a practicing primary care doctor, I believe that we, not the patients, bear this responsibility and that I hope doctors in training are being taught this routinely in this country and that others welcome the opportunity to do better. While it should be a required reading assignment for medical students, interns, residents, and practicing physicians, better thinking doctors alone aren't going to improve healthcare quality in the United States. Dr. Groopman's subtle suggestions that they might are simply his error in thinking and his inability to remain open-minded. The world he trained in is far different than the world his trainees are about to enter.

Better - A Surgeon's Notes on Performance
A fascinating and quick read. In each section there are plenty of inspiring stores about doctors making a difference. Dr. Atul Gawande, a general surgeon at Brigham and Women's Hospital and staff writer for the New Yorker has keen observation and insight to make single stories demonstrate not only the failings of our healthcare system but also the solutions to them because of individuals asking questions on how to do better. Ultimately, one of the questions he asks is how can doctors and hospitals be positive deviants? How does one become a positive deviant or an outlier that pushes beyond convention and advances patient care to new levels?

He gives examples of how over four million children need to be vaccinated in Northern/Southern India in three days to prevent a large polio outbreak. An immunization rate of less than 90 percent would be considered a failure.

Dr. Gawande talked about the evolution of obstetrics. After a damaging report in 1933, the specialty consequently committed itself to standardizing childbirth ensuring that with the new medical knowledge that it was applied consistently and routinely throughout the country. As a result maternal death in childbirth fell 90 percent from one in 150 in the 1930s to one in 2000 by 1950s. With continued innovations and the commitment to do better, the chance of a woman dying in childbirth is less than one in 10,000 today.

There are plenty of amazing examples that you don't have to be a doctor to relate on how truly inspirational these individuals are in times when the stakes could not be higher - life or death.

Until our healthcare system improves to its full potential as Dr. Gawande challenges us to do, unfortunately will always remain benefiting those who are insiders and harming those who are not. The real question is which one are you? This failing is part of the reason for the rise of the empowered patient movement.

Innovator's Prescription - A Disruptive Solution for Health Care
The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. The authors, respected Harvard Business School (HBS) professor, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School, and another doctor and graduate of the MBA program at HBS have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Physician Autonomy, Professionalism, and Protocols – Mutually Exclusive?

2011-06-12T10:48:00.000-07:00

Doctors are professionals. But are doctors cowboys or pit crews? Recently, physician writer, Dr. Atul Gawande, spoke about the challenges for the next generation of doctors in his commencement speech titled, Cowboys and Pit Crews, at Harvard Medical School. Gawande notes that advancement of knowledge in American medicine has resulted in an amazing ability to provide care that was impossible a century ago. Yet, something else also occurred in the process.

“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”

Despite all of the advancements in medicine, the outcomes and consistency in treatment and care are not as good as they could be. Doctors are not doing basic things. The fact that Gawande, author of The Checklist Manifesto, spoke at one of the finest medical schools in the country indicates how much more the profession needs to go.

“We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

So what is the issue?

Doctors usually bristle when facts of failure are mentioned. When solutions are offered, a variety of reasons of why they won’t work often occur. Doctors deal with patients and illness. Medicine is different from other industries like aviation or auto manufacturing in their experience with providing a highly consistent and reliable service or product. In many ways, this is true. Patients are unique in their genetic makeups, personalities, backgrounds, and experiences. Yet, the understanding of many illnesses has evolved to the point that doctors understand how to prevent, screen for, and treat these maladies which often afflict patients in similar ways. When understood at this level of detail, this knowledge can be codified into protocols and workflows. As research studies demonstrate what works and what does not, these can be refined further. Analysis of medical errors borrow the same processes and tools from other organizations dealing with complex systems to determine underlying problems and more importantly solutions to avoid similar outcomes in the future.

The creation of standardized workflows, checklists, and protocols causes doctors to bristle even more. As Gawande notes, the training of doctors today is essentially unchanged from generations ago which valued physician autonomy. When asked to follow protocols, doctors often feel this freedom to practice medicine is threatened. A natural tension exists between physician autonomy and adherence to protocols. Many will argue that the two are mutually exclusive. Both, in fact, can co-exist only if we look at the problem through a different lens. It is about the difference between what Professor Clay Christensen, Harvard Business School professor, and author of the Innovator’s Prescription, calls intuitive medicine and precision medicine.

It is also about professionalism. Are doctors professionals or cowboys or pit crews?

What Professor Christensen refers to as intuitive medicine is essentially how the public and doctors view themselves. As a result of the medical training, history, and tradition, doctors are thinkers. Patients present themselves with a set of symptoms or signs that they want doctors to solve. Because the body only has a certain limited number of ways to manifest an illness (note that for a dermatologic disorder, the skin turns red and can blister due to a burn, drug rash, autoimmune disorder, or contact dermatitis), clinching the right diagnosis required doctors to ask questions, think, use pattern recognition, and experimentation. Until the relatively rapid learnings over the past century, doctors did not understand the specific mechanisms, pathophysiology of diseases, or the appropriate treatments.

An example of intuitive medicine was an illness that humbled American medicine just three decades ago. It afflicted mainly young gay men. Aside from the observations of a low T cell count and unusual opportunistic diseases affecting these patients, doctors were at a loss of what to do. How did the illness occur? How was it transmitted? How as it treated? The fear among the public was palpable. During that time, doctors tried a variety of treatments that invariably failed though through some experimentation and observation, some patterns began to emerge. The reasons for a few successes became better understood when HIV was discovered and doctors had a better understanding of AIDS. As a result, the course of illness and then the development of therapies, treatment, and prevention programs occurred which now allow individuals with HIV to live productive lives.

When scientific understanding of maladies becomes so clear that prevention, screening, and specific therapeutic options can be written down into steps, protocols, and workflows, Professor Christensen refers to this type of medicine as precision medicine. Many medical problems, like diabetes, are in this category.

The pathophysiology of diabetes is known. There are two types of diabetes, insulin dependent and non-insulin dependent diabetes. The degree of blood sugar control can be determined with a simple blood test, HgbA1c. If a patient has insulin dependent diabetes, the treatment must begin with insulin. For non-insulin dependent diabetes, treatment can often start with weight loss, physical activity, and dietary changes. Prescription medications, like metformin, and then later glipizide can be added in a stepwise approach based on a specific protocol should an individual patient’s blood sugar control require it. The fact that the understanding of diabetes and development has occurred over the past few decades has benefited Professor Christensen greatly. He has insulin dependent diabetes. Had he been born a century ago, he would not have lived very long as insulin was not discovered until the early 1920s.

Yet, there are some areas in diabetes research which continue to evolve. Intensive blood sugar and blood pressure control in patients with insulin dependent diabetes was found to decrease the risk of complications and death. It was assumed and extrapolated that similar treatment would also benefit those with non-insulin dependent diabetes. Recently studies have shown that older patients did not benefit and perhaps were harmed with this level of treatment. As a result, the guidelines have changed.

Although the protocols and guidelines are good, they are not perfect. They are only as good as the research available at that time. They continue to be refined. They are not static. It is this element that opponents of using precision medicine shout out words like “cookbook medicine” which have significant negative connotation. This simply denigrates the hard work and research that has allowed an illness to move from the realm of intuitive medicine to precision medicine. The fact that these protocols are not perfect, should not be a reason not to use them.

At the heart of being a professional and consummate physician is the knowledge and wisdom to understand when a patient’s illness or treatment of a condition fits a known workflow or protocol and when it does not. The very best physicians follow procedures meticiously and thoughtfully whether placing a central line using the five critical steps as outlined by McArthur grant recipient and John Hopkins critical care specialist, Dr. Peter Pronovost, to eliminate risk of infection or taking seriously a surgical timeout to avoid wrong site surgeries.

Too often doctors will argue that blindly following protocols infringes on their autonomy. That is true. Blind adherence is a problem. However, passively going through the motions is equally as disasterous.   Life saving treatment isn’t rendered. Screening tests not offered.   Preventable medical errors still occur. In November 2010, only six months before Gawande’s commencement speech, a wrong site surgery case was prominently profiled in the New England Journal of Medicine. It occurred at one of the nation’s most prestigious hospitals, Massachusetts General Hospital.

In the end, it is the mindset of physicians which matter. We aren’t cowboys. We aren’t pit crews. If analogies must be made, then we are like the pilots in flight crews who are professionals and despite the complexity of their roles provide ultrasafe travel. Doctors are professionals. It is what the public expects. Using protocols, checklists, and standardized workflows are just as important as refining them to be even better. Knowing when not to apply them, is just as vital as ensuring that those situations where they do apply that they are done - every patient every time.

Our patients deserve better. We can and must do better.

What Dr. Oz Learned From His Cancer Scare - Honest and Unplugged. What Doctors Can Learn.

2011-06-02T15:56:00.000-07:00

Dr. Mehmet Oz recently had a piece in Time titled "What I Learned from My Cancer Scare" in which he became the the more humbled Mr. Mehmet Oz. As noted previously here, Dr. Oz last summer had a colonoscopy at age 50 and much to everyone's surprise had a precancerous colon polyp. He was advised to follow-up again for a repeat test in 3 months.

As the Time magazine piece noted, he didn't return for 9 months despite repeated reminders from his doctor.

From this experience, he essentially stumbled upon what has been challenging American medicine and primary care. How do we enable patients to do the right thing and get the screening tests done and treatments necessary to avoid premature death and maintain a high quality of life? As a highly trained professional, Dr. Oz knows the risks and benefits of not doing a preventive screening test. As a doctor, he knows all of the secret protocols and codespeak we use when calling patients or asking them to see us in the office for important matters. As a doctor, he also understood the importance of a repeat colonoscopy to ensure no more colon growths.

Yet he didn't return for 9 months. Why?

None of us want to deal with our mortality. Having a screening test means there is a possibility that the test may be abnormal and now we must confront it face to face. Skipping the test means to be blissfully ignorant, even if it is the wrong thing to do.

Also, as Dr. Oz noted, many individuals, particularly those who are otherwise healthy with no family history, feel that many of these tests or interventions don't apply to them. Trust me, I know. As a practicing primary care doctor, do you know how hard it is to convince someone to get screened for colon cancer? Get vaccinated for pertussis, influenza, or pneumonia?

Dr. Oz, however, did discover what will compel people to do the right thing. It isn't about statistics. It isn't about knowledge. (And though he never discussed it, it certainly won't be consumer driven health care where the theory is that forcing people to have more financial "skin in the game" will enable the right behavior). It's about getting to our emotions.

Most important, my colonoscopy wasn't entirely about me. It was about my wife and our children. It's about our someday grandchildren. It's about my childhood friends whose lives remain closely intertwined with mine. It's about my colleagues and patients at the hospital who teach me as I learn from them. I need to be there for all these people I know and care about. I need to show up in my own life. And you need to show up in yours. Sometimes that requires courage — the courage to undergo a colonoscopy or Pap smear or mammogram or chest X-ray. It's not easy, but it could save your life. And if it helps even a little, remember that I will be rooting for you.

Reminding our patients that their inaction isn't just affecting their own livelihood but their network of family and friends. It's the reason why certain topics in the media, like the concerns about vaccine safety and autism, gain far more momentum than the scientifically researched and proven life saving interventions and treatments do.

They focus on the emotional aspect of us that make us uniquely human.

Until we, as doctors, employ those same tools, too many Americans will not learn from Dr. Oz's cancer scare or those from a variety of public figures. The same problems will simply repeat themselves, just different people become spokespersons (note Katie Couric from a decade earlier regarding colon cancer screening).

Though highly unlikely Dr. Oz will ever read this article, one thing he must do is to highlight the need for a robust primary care workforce and inspire a generation of doctors in training to become the front-line of prevention. Despite his work as a public figure, the intimate and personal conversations needed about preventive tests and treatments happen one on one at a primary care doctor's office. And we certainly need a lot more of us to get the job done.

The Disappearing Family Doctor - Is It a Bad Thing?

2011-04-25T10:56:00.000-07:00

The New York Times recently published an article titled the Family Can't Give Away Solo Practice wistfully noting that doctors like Dr. Ronald Sroka and "doctors like him are increasingly being replaced by teams of rotating doctors and nurses who do not know their patients nearly as well. A centuries-old intimacy between doctor and patient is being lost, and patients who visit the doctor are often kept guessing about who will appear in the white coat...larger practices tend to be less intimate"

As a practicing family doctor of Gen X, I applaud Dr. Sroka for his many years of dedication and service. How he can keep 4000 patients completely clear and straight in a paper-based medical system is frankly amazing. Of course, there was a price. His life was focused solely around medicine which was the norm of his generation. Just because the current cohort of doctors wish to define themselves as more than their medical degree does not mean the care they provide is necessarily less personal or intimate or that the larger practices they join need to be as well.

The New York Times article and many patients typically confuse high quality care with bedside manner. Not surprising. In the November 2005 survey by the Employee Benefits Research Institute, 85 percent or more of the public felt that the following characteristics were important in judging the quality of care received:

The skill, experience, and training of your doctors
Your provider’s communication skills and willingness to listen and explain thoroughly
The degree of control you have in decisions made regarding your health care
The timeliness of getting care and treatments
The ease of getting care and treatments

The first three items relate to the ability of a doctor to translate knowledge, training, and expertise into the ability to listen, communicate, and partner with a patient. This is bedside manner. The last two items relate to whether a patient can be seen quickly and easily when care is needed.

But beyond bedside manner and ease of getting care, both which are very important, does the public care about getting the right care or just assume that it is a given? My suspicion is that they assume all medical care provided by doctors is the same, yet research demonstrates the contrary. One study found that 75 percent of primary care doctors provided the wrong type of colon cancer screening. Those most likely to do the wrong test after a positive stool screening test? Those who graduated from medical school before 1978, who were not board-certified, and who were in solo practice.

Personal relationships between doctors and patients are important, but that should not be the only criteria regarding high quality care.

I love primary care. I've worked at Kaiser Permanente (KP) in Northern California since 2000, a "larger practice". The number of patients a full-time doctor cares for is about half of the 4000 patients of Dr. Sroka's. Doctors have access to a comprehensive electronic medical record that provides real-time information about a patient's lab work, imaging studies, and medications 24/7. Primary care doctors and specialists can collaborate working off a common database and eliminating the uncertainty that exists in a paper based medical system and when doctors work in isolated solo practices. Our primary care doctors are supported with a call center which is open all year round day and night to provide patients advice on symptoms and advice on when problems can be safely cared at home, when a doctor's appointment is needed, or when medical care is more emergent.

In other words, doctors can be doctors.

Let's not assume or confuse the rising trend of large group practices or the implementation of more electronic medical records and technology in doctors' offices as automatically dooming doctor-patient relationships to becoming more impersonal. The rise of social media like Twitter and Facebook have increasingly made society more connected than ever.

If Americans and doctors want solo practices, then they will demand them. Certainly there are successful solo practice models like the Ideal Medical Practice, which also supported by information technology, that can provide patients with a doctor who is a sole proprietor. To say all primary care doctors should join large group practices should be absurd because doctors like patients are individuals and one type of practice does not fit all.

Yet, the fundamental problem with this New York Times piece is the implication that solo practices provide doctor-patient relationships that are more intimate and where patients have a level of trust and confidence in doctors that perhaps exceeds that of thoughtfully designed larger practices. It offers no evidence if the quality of care delivered is as good. Let's not use a practice model which was prevalent in the 1960s and assume its passing is a bad thing. It may not be up to the challenges of the 21st century.

Does America Want Apple or Android for Health Care?

2011-04-13T21:53:00.000-07:00

The future direction of American health care is unclear. Certainly the cost trend as it exists is unsustainable with health care costs being a major concern of the private sector, the government, and individuals. How does the nation manage costs while ensuring high quality medical care, access, and service? Proposals include increasing competition among insurers, providers, and hospitals to drive down prices or giving more financial responsibility to patients via higher deductibles and co-pays with the belief that they will demand price transparency, shop around for the best price, and as a result slow health care costs.

What if both ideas are wrong?

While it is possible these plans might work, I cannot help but notice the similarities in the challenges for patients in navigating the health care system and consumers figuring out how to purchase and use technology. Walk into your neighborhood electronics store. Individuals are overwhelmed with the number of product choices, manufacturers, differences in technical specifications and features. In the majority of situations, consumers are unsure of what they are purchasing. They want something that just works, whether surfing the internet, making home movies, or being connected with loved ones. The gap in knowledge between an expert and a consumer is great and often unintentional and unapparent.

Within the technology world, there are two groups of thought. The first group offers technology in a closed system, like Apple, where the focus has been on just making things work. There are a limited number of product types and designs. For example, its current smartphone, the iPhone 4 comes in only two types. Aside from the base memory of 16 GB or 32 GB and two different prices, the phones are otherwise identical in features with the same apps, cameras, and ability to record video. Although the specifications are available for anyone to see, the focus is rarely on the technical elements of the products themselves and more on what they can do for you. Walk into any Apple retail store and the products are situated by function. Staff ask not how much computing horsepower, storage space, or CPU speed one needs, but what one plans on using the smartphone or computer for.

In contrast, Google's sponsored Android platform, which runs smartphones from a variety of manufacturers gives consumers maximal choice. Companies like Motorola, Samsung, HTC, and LG offer a variety of combinations of styles, features, and ironically even different software versions at various price points. Verizon and AT&T wireless offer no less than 10 different Android based smartphones. The amount of choice and options could be intimidating. While potentially an Android smartphone could be cheaper than a comparable Apple iPhone, people often fail to account for all of the time and energy spent on researching, thinking, and also potential worry and buyer's remorse that the right choice was made. The time and energy spent does cost, either monetarily or emotionally.

Which one would you choose? A system which just works, gets the job done, and has been designed to fulfill most of your needs? Or alternatively, a different system which provides more choice, more options, and in many cases, requires more time to research and become an expert to make the best decision?

If you look at proposals and trends in health care, it appears many are advocating for Android.
To manage costs, consumer driven health care, where patients have more financial responsibility via the addition of deductibles and higher co-pays are felt to be the answer. The patient is the party accountable to having the right tests done, finding the right doctors, reviewing and maintaining their medical chart using personal health records, and shopping around for the best price when it comes to imaging and other procedures. After all, who has the most motivation to make the best choice but the individual who's life depends on it?

Increasingly there is research that shows people are decreasing health care costs. Unfortunately it is not the behavior of avoiding expensive excessive care (opting to see a primary care doctor rather than the emergency room for non-emergent evaluation) but skipping preventive tests, prescription medications, follow-up evaluations to treat chronic conditions at the early stage to prevent future complications. If true, the implications of these small inconsequential choices by patients could be problematic years later.

Also similar to Android philosophy, others argue for more competition. With the consolidation of insurers and in some case providers and hospitals over the years, understandably many are concerned that prices are driven higher through monopoly power. Instead, the belief is that having many insurers, providers, and hospital networks will improve health care as they compete for patients on areas of service, quality, and access. The market will reward those who are best in providing all three. With the large number of competitors, groups will be unable to have pricing power and therefore costs will be managed.

Providing patients plenty of choices is proposed as the key to fixing the health care crisis. Perhaps this is the reason for the creation of insurance exchanges in the recent health care reform legislation. Patients will have the opportunity be to select health insurance plans which are not tied to their place of employment. Let them figure out which insurance plan is the best. Have them figure out which doctors take their insurance and are the best. They can select from their menu of different hospitals and determine the best one for their needs.

Is there another way? Would patients prefer a different system which is integrated and seamless and where patients can focus on simply getting better and not spending time and energy trying to figure out where to go and who to select?

One example might be where I work, at Kaiser Permanente in Northern California, a vertically integrated organization with health plan, hospitals, and doctors working together to provide care that is convenient, simple, and personal for our members. Dr. Atul Gawande in his June 2009 New Yorker piece, the Cost Conundrum noted places like Grand Junction, Colorado, were able to provide high quality care at lower costs when doctors worked together. Other organizations which were physician led and accountable also had similar outcomes.

Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Perhaps this is the reason for the creation of Accountable Care Organizations in the health care reform legislation. Whether the legislation and regulations can foster and replicate similar organizations and outcomes remains to be seen. What I can tell you is that within my organization, doctors, nurses, and support staff are working hard to improve how care is delivered to our members much the same way I suspect software engineers and designers at Apple focus on their technology to make it intuitive and so it just works.

Perhaps there is no illustration better of the potential of American health care than the words from a patient.

Here's why I chose Kaiser for my medical needs at age 25:
    1.    I liked their Web site.
    2.    It was easy to set up appointments over the phone and via the Internet.
    3.    They have a 24-hour Advice Nurse phone line which is helpful if your parent is not "just a phone call away".
    4.    Through the Web site you can choose a primary care physician and OB/GYN by location, gender, and bio. If you don't like your choice you can always change it later.
    5.    You can email non-urgent messages to your doctor through the Web site and your doctor has to respond within 48-hours.
    6.    The Kaiser Web site will send you an email when test results are available online.

At age 29, here's why I know Kaiser was the best decision I ever made:
    1.    When I was brought to the Kaiser emergency room after my first seizure the staff was able to retrieve my complete medical history, which aids staff in making decisions about my care ... even when I'm unconscious.
    2.    After scans revealed I had a tumor in my brain, the head of neurology came down to see me and had me admitted to the hospital that night.
    3.    My newly acquired neurologist arranged for my transport to the neurosurgery center for the Sacramento region.
    4.    Once I got there I worked with Kaiser's neurological equivalent to Dr. House, except this doctor was way nicer.
    5.    My neurologist, neuro-surgeon, oncologist, neuro-oncologist, OB/GYN, primary care practitioner, orthopedic doctor, and physical therapist are all informed about my medical status.
    6.    I never have to seek, or wait for, a referral. If a new specialist is needed for my care I get to see him/her as soon as I'm able to get a ride.
    7.    I can get lab work done at any Kaiser facility and the test results are sent electronically to the requesting doctor within minutes/hours (or a few days if it's analysis of brain tissue).
    8.    Kaiser specialists network with peers from other medical institutions and often seek second and third opinions for you. They'll even tell you who disagreed with them and why. If you want to get the second opinion yourself they are respectful of your decision and make sure you get all required materials to make this happen (e.g., charts, scans).
    9.    After my most recent brain surgery, my tissue was analyzed by pathologists in Sacramento and Oakland, then sent to Kaiser in Redwood City, who sent it along to UCLA.
    10.    While my friends and I did a lot of our own research, Kaiser made it easy for us to get treatment. We never had to figure it out all by ourselves and my doctors/nurse practitioners answered every question I had ... even the silly questions.

The future of American health care is unclear. Do Americans what Apple or Android for health care?

Let's let them decide.

The Rise of Desktop Medicine -- Wrong Terminology, But Right Thing to Do

2011-04-01T23:42:00.000-07:00

A recent NY Times article, the Rise of Desktop Medicine, highlighted the use of technology in accessing information (desktop medicine) and how doctors were spending less time with patients (bedside medicine). Many doctors were concerned about the change and longed for the old days. Yet, the reality is that with more medical knowledge, doctors must retrieve information from clinical trials, calculate risk of heart attack or osteoporosis, rather than rely on intuition, particularly when data exists.

My biggest problem with this article really was with the term desktop medicine. I don't like it. Certainly over the past few decades, our understanding of certain illnesses has become more precise, the interventions and treatments more clear, and therapies more evidence based (precision medicine). Other illnesses, however, still continue to be more challenging and determining the correct course of action less clear (cognitive or intuitive medicine).

Precision medicine, a term used by Harvard Business School Professor Clayton Christensen, has simply occurred at the same time computers and the ability to rapidly access information developed. Imagine if medical science knowledge had evolved but that there was no infrastructure or technology available to retrieve information like clinical trial outcomes quickly. Doctors would still be treating patients based on intuition rather than science completely oblivious to the latest knowledge. Research has shown it takes 17 years before outcomes from research studies become commonly practiced in the community.

No desktop medicine isn't the right term to describe the phenomenon in medicine. It implies doctors are simply indentured servants to computers and technology. Nothing could be further from the truth. Generations ago, doctors had few tools and treatments. When people developed pneumonia, we could do nothing but wait and hope because antibiotics were not discovered yet. We simply comforted individuals and families. Many people died.

Today we have more tools, more treatments, and a better understanding of many, but not all illnesses. To say this additional knowledge and the ability to retrieve this information somehow erodes the doctor patient relationship is incorrect. We can still be caring and use our technology to access information to make the care of the patient in front of us more precise and personalized than ever before.

No, the terms desktop medicine and bedside medicine are incorrect because they provide the wrong type of connotation. The former term implies cold and impersonal. The latter term suggests humanity and comfort. Better terms with less emotional attachment would be precision medicine and intuitive or cognitive medicine.

I'm a big fan of the art of medicine and bedside manner. I also love how my computer allows me to make care more convenient and more personal.

The next generation of doctors must be experts at both bedside manner and using the vast knowledge of medical science to make care precise in areas we have good understanding. For illnesses where we don't, we still do what we did generations ago, comfort and heal.

No computer will ever replace that.

Save Money on Medical Costs - Get Your Old Medical Records

2011-03-30T21:38:00.000-07:00

There are many tips to saving money on medical costs like asking your doctor only for generic medications, choosing an insurance plan with a high deductible and lower monthly premiums, going to an urgent care or retail clinic rather than the emergency room, and getting prescriptions mailed rather than go to a pharmacy.

How about getting your old medical records and having them reviewed by a primary care doctor? It might save you from having an unnecessary test or procedure performed.

Research shows that there is tremendous variability in what doctors do. Shannon Brownlee's excellent book, Overtreated - Why Too Much Medicine Is Making Us Sicker and Poorer, provides great background on this as well as work done by the Dr. Jack Wennberg and colleagues on the Dartmouth Atlas. Some have argued that because of the fee for service structure, the more doctors do the more they get paid. This drives health care costs upwards significantly. Dr. Atul Gawande noted this phenomenon when comparing two cities in Texas, El Paso and McAllen in the June 2009 New Yorker piece.

Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.

Doctors apparently seemed to order more tests. Patients, not surprisingly, agreed. After all, without adequate medical knowledge or experience, how sure would you be if a doctor recommended a test and you declined?

Would doctors do more because they get paid more or would they simply do the right thing and do tests or procedures when only medically necessary?

I recently had a 55 year old healthy woman join my practice. She wisely had brought in her medical records and was fairly educated on the care she received. She told me that her previous doctor had recommended a colonoscopy for this year, five years after her initial colonoscopy at age 50.

Odd.

For most patients with no family history of colon cancer and a normal colonoscopy, recommendations are to repeat in ten years not five.

Did she have any abdominal pain or change in bowel habits? No.

Did the doctor say anything about colon polyps or growths? No.

Did she have the colon biopsied? No.

Was there a family history of colon cancer? No.

She was pretty sure she was to have a repeat test five years later.

I reviewed her previous doctor's chart which had her colonoscopy report.

Completely normal colonoscopy. No polyps. No growths. No biopsy.

At the end of the report: Recommend repeat colonoscopy in 5 years.

I've read news reports over the years where research has noted some gastroenterologists were doing colonoscopies more frequently than recommended by their own professional medical societies either for routine screening or follow-up of colon polyps and growths. I assumed those stories were outliers and rare. I would never encounter such an obvious case of overtreatment.

But this patient's report and her memory of what her doctor told her could not be chalked up to a typo or a misunderstanding. Would doctors do more because they get paid more? How else to explain this?

After showing my patient the guidelines from the American Cancer Society as well as the American College of Gastroenterology, she was thrilled that she didn't need to undergo the procedure for another five years. No need to do the prep that Dr. Oz did with the gallon of laxative and the loss of a day getting ready and then recovering from the side effects of IV sedation needed for the colonoscopy.

I saved her time and money and unnecessary treatment.

You should always have a primary care doctor review your old medical record, especially if you move or switch insurance plans. Another doctor's opinion and insight can be very important to counter this natural feeling of uncertainty. No one wants to make a bad choice. Patients aren't medical experts and generally don't want to be. Doctors who choose primary care do so because they want to care for the whole patient despite the fact it is among the lowest paid specialties and least attractive to medical students. Medical students are gravitating towards specialty care which are more procedural based and therefore have the opportunity to generate more income.

Unfortunately, this means doctors who can help patients make informed decisions and prevent overtreatment will be in limited supply at a time when we need them the most.

Colon Cancer Screening Guidelines - Colonoscopy Better Than Sigmoidoscopy? The Truth and the Myth

2011-03-06T21:52:00.000-08:00

Colon cancer screening has a particular personal interest for me. One of my colleagues in residency training had her father die of colon cancer when she was a teenager.

No one should lose a love one to a disease when caught early is often treatable. Although for both men and women, colon cancer is the third most common behind lung and prostate cancer in men and behind lung and breast cancer in women, it is the second most lethal.

The problem is that patients are often confused about which test is the right one. Is it simply a stool test? Flexible sigmoidoscopy? Colonoscopy? Virtual colonoscopy? Isn't there just a blood test that can be done? (No.)

In real simple terms, this is all you need to know.

All men and women age 50 and older should be screened for colon cancer. Even if you feel healthy and well and have no family history, it must be done. Note that Oprah's doctor, Dr. Oz, arguably a very health conscious individual learned that he had a colon polyp at age 50 after a screening test. Left undetected, it could have cut his life short. This wake-up call caused him to abort his original second season premier on weight loss and instead show the country why colon cancer screening matters. He admitted that if it wasn't for the show and the need to demonstrate the importance of screening to America, he would have delayed having any test done.

The least invasive test is a stool test. If it is to screen for colon cancer, then the test is done at home and NOT in the doctor's office. Either the fecal occult blood (FOBT) or the fecal immunochemical test (FIT) are available to screen for unseen microscopic blood that could be a sign of a colon polyp or cancer. Research shows that when done annually the risk of dying from colon cancer can fall by 15 to 33 percent. If you don't want any fiber optic cameras in the rectum and lower colon, this is the test for you. You must do it annually.

The next two tests are similar but often confused - the flexible sigmoidoscopy and the colonoscopy.

The flexible sigmoidoscopy examines the lower third of the colon, known as the sigmoid and the descending colon. Patients cleanse the lower colon by ingesting a small amount of laxative the day before the procedure. If a colon growth or polyp is found, it can be biopsied or completely removed during the procedure. The test is typically done in 15 to 20 minutes. Patients are awake for the procedure and can go home. Research shows this test can decrease the number of deaths due to colon cancer. The risk of the procedure is very small with about 1 in every 5,000 patients having a small tear or perforation. This flexible sigmoidoscopy test is done every 5 years.

Like the sigmoidoscopy, the colonoscopy also requires cleansing of colon, however, a gallon of laxative is require to empty the entire colon. Colon growths and polyps can be removed similarly. Unlike the sigmoidscopy, however, the colonoscopy requires that patients be sedated. As a result, you will need someone to take you to the appointment and drive you home. Although the procedure itself takes about 30 minutes, it can be a few hours from arriving to going home due to the anesthesia. Out of all of the screening tests, it is the most risky with an estimated perforation rate and cause of serious bleeding affecting in 1 in 1,000 patients. A colonoscopy is done every 10 years.

Would checking the entire colon with a colonoscopy be better than evaluating the lower third of the colon with a sigmoidoscopy? Evidence that colonoscopies save lives from colon cancer is lacking. This subtle but important point is often not mentioned in media reports. Even the NY Times perpetuated this belief that colonoscopy is the preferred test in its January 20th, 2011 article, "Why People Aren't Screened for Colon Cancer." When family medicine doctor and lecturer in health care policy at Harvard medical school, Dr. John Abramson, wrote a letter to the NY Times editor in February 15th, 2011, noting the this fact in an unrelated article, the American College of Gastroenterology (ACG) wrote a letter indicating that a colonoscopy is their preferred test for screening.

No wonder patients are confused.

If one dissects the ACG letter carefully, we note the following language (words bolded for emphasis):

American College of Gastroenterology’s 2009 colorectal cancer screening guidelines recommend colonoscopy as the preferred cancer prevention strategy, and guidelines by the American Society for Gastrointestinal Endoscopy in 2006 also endorse colonoscopy because of its ability to view the entire colon and remove potentially precancerous polyps, reflecting a strong opinion of these experts that prevention should be the primary goal of colorectal cancer screening.

While public health experts have recently debated the exact parameters to measure the impact of these screening strategies on mortality, a clinical picture that is muddied by the many variables affecting the quality of the examination, the jury is still out. Indeed colonoscopy’s protective power may lie in a growing appreciation that the biology of precancerous polyps and cancer is different in the right compared to the left colon.

In other words, the recommendation is based on opinion. There is no language indicating that there is evidence. The "protective power may lie" in such and such, but hasn't been confirmed. Examples of when doctors made opinions when evidence was lacking only to change their minds later include hormone replacement after menopause, bone marrow transplant for breast cancer treatment, and prostate cancer screening with PSA.

A study that appeared in the Annals of Internal Medicine in the January 6th, 2009 issue, researchers found that colonoscopies did cut down colon cancer deaths, but it was due to detection of the left sided colon cancers (sigmoid and descending colon) and not to the right side, of which only the colonoscopy can reach. In other words, a flexible sigmoidoscopy would have detected the cancers as well, which has been observed in previous studies.

Researchers reviewed health records for persons aged 52 to 90 who received a colorectal cancer diagnosis between 1996 and 2001 and died of colorectal cancer by 2003. These patients were compared to a control group who were selected from the population of Ontario and had not died of colorectal cancer.

According to the researchers, complete colonoscopy was strongly associated with fewer deaths from left-sided colorectal cancer. Conversely, the data showed that colonoscopy seemed to have almost no mortality prevention benefit for right-sided colorectal cancer.

So who do you listen to? I typically review the guidelines from the American Cancer Society (ACS). As a group advocating cancer screening and awareness, they should have no bias about what test to use to screen for colon cancer. For individuals at average risk for colon cancer, ACS notes that to find colon polyps or cancer, either a sigmoidoscopy every 5 years or colonoscopy every 10 years. Their recommendations don't say the preferred option is a colonoscopy. The Centers for Disease Control the US Preventive Services Task Force, and the National Cancer Institute also say little about which is preferred.

What does this mean to you? For those at average risk and no family history of colon cancer, get screened for colon cancer at age 50. At the bare minimum, do an annual stool test if you don't want an invasive procedure. Know that at this time there is no evidence that colonoscopy is better than a flexible sigmoidscopy.

If people tell you otherwise ask them to show you the evidence.

And let me know.

Why Consumer-Driven Health Care Will Fail

2011-02-22T08:25:00.000-08:00

The creation of consumer-driven health plans (CDHPs), health insurance policies with high deductibles linked to a savings option and with more financial respnonsibility shouldered by patients and employees and less by employers, was completely inevitable. The American public likes to have everything, whether consumer electronics or other services, as cheap as possible. With escalating health care expenses rising far more rapidly than wages or inflation, it's not surprising employers needed a way to manage this increasingly costly business expense.

In the past, companies faced a similar dilemma. It wasn't about medical costs, but managing increasingly expensive retirement and pension plan obligations. Years ago, companies moved from these defined benefit plans to defined contribution plans like 401(k)s. After all, much like health care, the reasoning by many was that employees were best able to manage retirement planning because they would have far more financial incentive, responsibility, and self-motivation to make the right choices to ensure a successful outcome.

How did that assumption turn out anyway?

Disastrous according to a recent Wall Street Journal article titled Retiring Boomers Find 401(k) Plans Fall Short.

The median household headed by a person aged 60 to 62 with a 401(k) account has less than one-quarter of what is needed in that account to maintain its standard of living in retirement, according to data compiled by the Federal Reserve and analyzed by the Center for Retirement Research at Boston College for The Wall Street Journal. Even counting Social Security and any pensions or other savings, most 401(k) participants appear to have insufficient savings. Data from other sources also show big gaps between savings and what people need, and the financial crisis has made things worse.

In others words a lot of people don't have enough money to retire. The options they have are simply "postponing retirement, moving to cheaper housing, buying less-expensive food, cutting back on travel, taking bigger risks with their investments and making other sacrifices they never imagined....In general, people facing problems today got too little advice, or bad advice."

Though employers were able to manage retirement expenses, employees paid a significant price. This wasn't intuitively obvious in the 1980's when these plans became more commonplace. Over the past decade, the less than rational behavior by employees hasn't gone unnoticed by those who study behavioral economics or those in the government. As a result, more organizations and companies are nudging employees into the right behaviors with auto-enrollment into 401(k) plans and auto-allocation of these funds with protection from any future liability as noted in the Pension Protection Act of 2006.

The analogies to health care and specifically consumer-driven health plans should be clear. Workers don't save adequately for retirement even when in their best interest. It's very likely that workers won't save money adequately to fund future health expenses. After all, if people can't fund retirement, something we undoubtedly all look forward to, which one of us is willing to saving for chemotherapy or open heart surgery, which no one wants? According to the annual Kaiser Family Foundation Employer Benefits Survey, the average annual deductible for single coverage and family coverage is nearly $2000 and $4000 respectively for health insurance plans that are health savings accounts (HSA) eligible. The deductibles are slightly lower in health insurance policies that are linked to health reimbursement arrangement (HRA). About 13 percent of employees are covered under either plan.

Unlike those in retirement planning who can work longer, even if not desirable, employees who are ill may not have an option to work to pay for their medical expenses. There continues to be evidence that people are curbing their health care due to the ability to pay.

Though experts debate on whether this is a good thing (patients are avoiding unnecessary and expensive therapies and opting for less pricey but equally as effective options) or a bad thing (patients are avoiding the preventive screening tests or therapies that overall can decrease future costs), the opportunities to ensure patients make the right choices should be clear from workers' less than optimal experience with 401(k)s.

If employers wish to help curb medical costs, then they will need to engage workers with programs like employee wellness, assisted decision making (either as second opinions or patient-friendly informed consent), and access to medical experts, equivalent to personal financial advisors, who may be able to help workers make the right choices for their health. Within the business community, there is some acknowledgment that access to these tools will be necessary to not only manage costs but keep employees healthy and productive.

Done correctly, consumer-driven health care can be what everyone hoped they would be, nudging healthy behaviors and slowing health care costs with workers selecting only cost-effective therapies. If implemented poorly and organizations simply shift health care costs and financial responsibilities to workers like retirement planning decades ago, the nation will need to accept more than ever that increasingly more people get the medical care based simply on their ability to pay and not on medical necessity.

As a practicing primary care doctor, I hope that day never comes.

What Doctors Wish Their Patients Knew - Critique of the March 2011 Consumer Reports article

2011-02-14T06:28:00.000-08:00

First, I'm a big fan of Consumer Reports and even listed their Consumer Reports Best Buy Drugs website in my book, Stay Healthy, Live Longer, Spend Wisely - Making Intelligent Choices in America's Healthcare System, because of its accurate, unbiased, and money saving information in getting the right treatments for the best price.

So naturally when I saw this month's issues cover story - What Doctors Wish Their Patients Knew, I had to read it. Overall, it was excellent and made a lot of sense. Their conclusions were obvious to me, however, might not be as intuitive to the public (after all it is titled what doctors wish their patients knew!).

In summary, primary care doctors matter and having a long-term relationship with one can save time and money. Respect and being courteous still matter to both doctors and patients. Thoughtful use of the internet might overcome the resistance doctors have to patients researching information. Generic medications, which are inexpensive and very effective for many conditions, are excellent and should be used.

A more in depth analysis reveals the following. Primary care doctors are vitally important. As Dr. Kevin Grumbach, professor and chair of the department of family and community medicine at the University of California San Francisco noted, "a primary-care doctor should be your partner in your overall health, not just someone you go to for minor problems or a referral to specialty care." Indeed, that is why I went into primary care. I prevent problems. I diagnose problems. On the occasion I can't solve your problem, then I need the assistance of my specialty colleagues.

I'm not a gatekeeper. I'm not simply a referral center or an obstacle in getting you the right care. In fact, I'm the first logical place to always get care and be your partner in keeping you healthy and well.

A long-term relationship with a primary care doctor is also important according to three-quarters of the 660 primary care doctors surveyed. Consumer Reports found some evidence that patients who frequently switch doctors have more health problems and spend more on care. This seems to make sense. Having someone you know and trust to get care over a long period of time can keep you healthy and save you money. The challenge for many Americans is trying to keep the same doctor. Employers often switch insurance carriers to save money. Doctors drop out of health plans. Patients change jobs and have a different health plan or no health insurance coverage. In other words, a primary care doctor isn't simply a commodity, but rather a vitally important relationship. Unfortunately the health care system and the general public don't view them that way. Practicing primary care doctors are leaving the specialty and medical students are not interested in a primary care field even though it is has potential to be one of the best choices in the future.

Respect and being courteous are two traits still valued by doctors and patients. The majority of doctors polled felt that being respectful and courteous would help get better care. Patients equated respect and courteousness as professionalism. Doctors who treated them respectfully, listened to them with understanding, and spent time with them scored high. Though professionalism scores increased more when patients felt that their doctor seemed technically competent, I find it hard to believe that patients can honestly determine who is skilled clinically. I think my car mechanic is skilled, but I really don't truly know as I'm not a mechanic.

I'm sure patients believe I'm technically competent as I explain everything I'm doing. For a knee examination, patients will hear me say - I'm palpating the meniscus both the medial and lateral aspects to check for arthritis or a meniscus tear. I'm examining the medial and lateral collateral ligaments of your knee and making sure they are intact and not strained or torn. I'm looking for fluid in the knee and mechanics of the knee with the range of motion. I'm checking the health and integrity of the ACL and PCL. Instead of wondering if I'm simply waving my hands like a magician, the description of the examination demonstrates my value as a doctor. Patients, and some doctors, have forgotten the value of taking a detailed history and a good physical examination. There was a time doctors didn't have the imaging tests of xray, CT, or MRI. Once I explain what I'm doing, then they understand why these tests are often unnecessary, which of course saves money and time. If showing and verbalizing our examination and thought process is professionalism, then we need to do more of it.

Although the article suggested that 80 percent of doctors felt taking a friend or relative to an office visit would be helpful, I believe this expectation to be a little unrealistic. Unless a family member or relative is particularly worried or if the visit is very important, say a consultation with a surgeon or an oncologist, it isn't necessary to have someone else tag along. People are incredibly busy. Taking time out of the day to accompany someone for an appointment isn't going to happen. The reason for this suggestion is that doctors discover patients don't typically remember everything that occurred in the office. This point really is about providing patients a strategy to recall important information (using the mneumonic D.A.T.E. can be helpful).

Suggestions on how to thoughtfully research information on the internet was a plus. Besides MedlinePlus and the Mayo Clinic, one should also consider Healthcare.gov, which has a preventive app, my health finder, that gives personalized specific age and gender information on what tests are needed and appropriate (it's under the Learn About Prevention tab). Not surprisingly due to the ease of looking information on the internet, 61 percent of patients have researched their condition. Sadly doctors were not as enthusiastic. Half of doctors said that online research was not helpful at all.

Physician wariness to the plethora of online information is due to the lack of respect from some patients who demand certain treatments, medications, or interventions, without understanding the nuance of a diagnosis. It isn't as simple, though it seems like it, as putting in a bunch of diagnoses and then just then hitting Google search (or worse I'm feeling lucky). I don't mind patients emailing me links to articles or suggest diagnoses. In fact, I learn a lot from patients. I do however find it difficult to treat patients who are insistent on their way or the highway and in those cases will suggest they find another doctor. It's about a trusting partnership not just about patients who are empowered with small pieces of information.

Finally, the best part of the issue was he Best Buy Drugs section which notes that many conditions, like high cholesterol, diabetes, heartburn, allergies, and depression have very good generic prescription medications that are inexpensive and very effective. Consumer Reports uses evidence based research to back up the claims. The vast majority of patients I care for do fine with generic medications. That's what I buy. You should do fine with generic medicationas as well. They left out my favorite online pharmacy, Healthwarehouse.com which often has pricing better than Wal-mart and Costco for many medications.

What else do doctors wish patients knew? Vaccines are safe and underutilized. Body scans and life line screenings really aren't worth your money. The fountain of youth really is eating less, moving more, and not smoking, and plenty of servings of fruits and vegetables. Cancer screening tests are for everyone, not those with family histories as the majority of people who develop cancer are the first in their family.

But of course, that might take more than just a blog post, but an entire book.

Why This Primary Care Doctor Loves his Electronic Health Record

2011-02-03T15:07:00.000-08:00

A recent post in the Wall Street Journal Health Blog noted that a study found electronic medical records don't improve outpatient quality. The authors of the Archives of Internal Medicine article, Electronic Health Records and Clinical Decision Support Systems, correctly points out that we should be skeptical and "doubt [the] argument that the use of EHRs is a "magic bullet" for health care quality improvement, as some advocates imply."

This should surprise no one. Were we that naive to think that simply installing health information technology (HIT) in the medical field would generate significant improvement in outcomes? Does simply installing computers in our classrooms improve educational test scores?

Of course not.

The excellent commentary after the article makes some plausible reasons why the clinical decision support (CDS) didn't seem to improve outcomes on 20 quality indicators. First, it isn't clear that the CDS implemented across the various doctors' offices and emergency rooms actually addressed the indicators studied. Second, the data studied is already dated (from the 2005 to 2007 National Ambulatory Medical Care Survey), a long time in technology terms (iPhone first debuted in 2007). The authors of the original article also point out that there is some evidence that institution specific use of CDS actually improves quality. Whether this can be scaled to the national level is the question.

In other words, it isn't just that perhaps CDS failed, but rather the robustness of the system was inadequate, that doctors failed to use them, or just as importantly patients were unswayed by the doctors reminded by the CDS to do the right thing. One of the 20 quality indicators studied was in fact the appropriate antibiotic use in viral upper respiratory infections. As most people know already, there is not typically an appropriate antibiotic to use for a virus. It's a virus. It does, however, take good bedside manner to inform and educate an ill patient!

As someone who has had the benefit of a robust electronic health record since the spring of 2006, I know I'm incredibly lucky. In an April 2009 New England Journal of Medicine article, only 4 percent of doctors nationally have a fully comprehensive EHR that I take for granted daily. Only 1.5 percent of hospitals have a comprehensive EHR, which I also have access to. CDS is also an incredibly helpful tool and an excellent reminder to provide the right care every time. It is a safety net. Understandably some EHRs aren't that good, the CDS is clunky, and certainly the one I use is good, but not perfect.

The real issue isn't finding a perfect EHR, but rather how do we address the culture of the medical profession. There is something still heroic and mystical about a lone doctor, independent, smart, and getting the job done. Indeed, to get into medical school, one has to be self-motivated, persistent, and determined. Why on earth would we need a computer to help us?

Frankly, because it makes us better doctors. CDS frees up time and mental energy. I don't have to remember the latest guidelines on immunizations, repeating blood work, or treatment of illness like coronary artery disease, congestive heart failure, and hyperlipidemia. Most of these diseases are well understood and often under a protocol, something known as precision medicine, a term used by Harvard Business School professor Clayton Christensen.

Now I can focus on if the patient in front of me is an exception to the protocol as well as thoughtfully diagnose and treat their ailments which don't fit any protocol (cognitive medicine) because science hasn't evolved to that level of understanding. I'm a big believer in the history and physical exam and how the use of HIT can make care more personal. Having real-time access quickly and reliably to medical information and data 24/7 is important to make this happen. Instead of hunting for lab work in a paper chart or trying to find a specialist's consultation, I can access the information I need rapidly and focus on the patient in front of me.

Sadly, however, many doctors don't feel the same way. Perhaps it is a generational thing. Perhaps it is because their EHR is inadequate. It might also be, however, our training and tradition which limits us from improving. If anything, the medical profession needs to emulate ourselves after the aviation industry where technology is used to support decision making and make pilots and flying even safer and better. We are where our aviation colleagues were in 1935 as noted in Dr. Atul Gawande's New Yorker piece, the Checklist. Because, really, CDS is essentially a checklist.

In the situation where a patient doesn't fit CDS, then we get to do what we do best and that is use all of our training to get a patient better. HIT, EHR, and CDS are things the next generation of doctors must accept that will make the care we provide more personal than ever before. In the end, that is what patients really want.

This is why I love my EHR so much.

Why the End of Internal Medicine As We Know It - Might Be A Good Thing!

2011-01-23T07:27:00.000-08:00

A recent blog post in the Health Affairs blog proclaimed The End of Internal Medicine As We Know It. What the article is really asking is the future of primary care in the world of health care reform and the creation of Accountable Care Organizations (ACOs). While doctors should be naturally concerned about change, I don't completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient's or employer's health insurance premium, something that is sorely lacking in the current health care structure. These were recently created and defined in the health care reform bill.

Yet, the author seems to suggest that this is a step backwards.

modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions

Not true. Successful organizations are ones that are tightly integrated - Apple, Fedex, Wal-mart, Disney.

The author talks briefly about how Europe in general does better than the US in terms of outcomes and costs and has a decentralized system. All true. However, contrasting Europe and America isn't relevant. After all, who isn't still using the metric system? Therefore solutions found outside the US probably aren't applicable due to a variety of reasons. Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago, like labeling primary care doctors (internists and family physicians) as "gatekeepers" rather than what we really do, never happens.

I love primary care. I've worked at Kaiser Permanente (KP) in Northern California since 2000. I have long term relationships with my patients. They see me when they are well. They see me when they are sick. They have me as their personal doctor. There are no mid-level practitioners (nurse practitioners or physician assistants) in my unit. I'm supported by information technology, staff to help those members with chronic conditions, and collegial specialist colleagues.

In other words, I'm doing what almost every primary care doctor wants: long-term meaningful relationships with patients, no hassles from insurance companies, the ability to retrieve information quickly and easily, and support for specialty colleagues who are equally focused on the well-being of the patient and who respect me as much as I respect them.

Perhaps the death of primary care as it currently exists with crushing administrative hassles, loss of work-life balance, increasingly short office visits, and paper charts which often has inadequate information or are unavailable isn't a bad idea after all.

Now I understand that KP looks very much like an ACO. I also know it isn't for everyone, doctors or patients, and isn't the only solution for the country. Certainly doctors should be wary of if every self-proclaimed "ACO" is really that or more of the same in the fee for service world but simply disguised in the ACO term.

However, for primary care doctors looking for a better way to care for patients, it is a very viable and sustainable solution. If the future for primary care looks like what I see and do everyday, then I believe the future will be bright.

Primary care doctors looking for a better future in primary care and willing to move to Northern California should do more research here.

Patients in the end may benefit from ACOs. I know my patients do.

Patients Lie. Why Doctors Should be Like Medical Students. A Good History is a Checklist.

2011-01-12T06:51:00.000-08:00

The most common question first year medical students ask me is how do they become efficient at taking a patient history. Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active? When can they stop asking about the review of systems, a list of questions asked about each organ system? A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.

Patients lie and don't even know it. It's not that they mean to. In fact, they are trying to be helpful when giving a history of their symptoms. Medical students concerns about taking a fast history reflects two things. First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past. Second, more importantly, is their fascination and desire to get started on real medicine -- what are the diagnoses, treatments, and tests that must be learned to be a good doctor.

In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening. Taking a good history is the essential part of being a good doctor.

Here are two examples of patients who I saw during the winter. The practice is busy this time of year. I'm often running late. Like many encounters, I've never met these patients before. In many ways, it can feel like an urgent care practice. Which patient is lying? Can you tell?

Young woman wanting a work note for the flu. She was complaining of a three day history of diffuse muscle pains, headache and high fever. That's it. She had no other concerns. Just anxious to get home and go to bed.

OR

A young man with an ankle injury after playing soccer. As an aside, he also asked about stomach flu which occurred a few days prior. He had nausea, abdominal pain, and vomiting for a day. He still had abdominal pain.

Which one was lying? Both.

A medical student or doctor recently out of training might have not missed the diagnosis in either patient because they are still working on how to hone down their questioning. In other words, they haven't take the shortcuts yet and still ask comprehensive histories. Yet, they aspire to just ask the vital questions to be efficient. A more seasoned doctor who is stressed and busy may have taken mental shortcuts and moved on.

In other words, how do you know what is and isn't vital until you ask?

Patients also have fallen into this trap believing this tradition of talking to their doctors is simply unnecessary, worthless, and an obstacle to getting to the truth. With increasing out of pockets costs for office visits, I'm seeing more requests from patients to simply get a MRI or blood test instead of seeing a doctor not only to address the problem, the real reason for the tests, but also if testing is usually necessary (it isn't in the vast majority of cases).

A good history is very much like the checklists pilots use and what Dr. Atul Gawande advocates in his book. Taking a good history also slows doctors down and allows them to avoid cognitive errors (as described beautifully in the book How Doctors Think), think more clearly, and avoid jumping to premature conclusions. Even the time honored skill of thinking through a differential diagnosis and thinking hard to make a long list of possibilities is a checklist and safeguard to consider other alternative problems that wouldn't appear when stressed. Being a doctor requires thinking and less knee jerk responses.

So what did the two patients have?

The first patient didn't have the flu. She had a kidney infection known as pyelonephritis. In taking the review of systems when asked about her urination pattern, she realized that it had changed during her illness. Also, in asking questions, she had no other signs of having a upper respiratory illness, no cough, no runny nose, no head congestion. Instead of simply writing a work note for a presumed virus and moving on to the next patient, this patient received antibiotics. Untreated, pyelonephritis can be serious and require IV antibiotics or hospitalization.

The second patient didn't have stomach flu. In fact, patients also make similar mental shortcuts by telling us what they think is going on - "stomach flu" rather than telling us specific systems. When people refer to stomach flu, like food poisoning, often there is nausea and vomiting which then is followed by diarrhea. He didn't have diarrhea just persistent abdominal pain.

He had gastritis, irritation of the stomach lining, due to alcohol abuse. Asking about his social history, he admitted to binging on a 12 pack of beers that day, a behavior, not uncommon for him. Not only was he treated for this, he was also recommended to quit drinking.

So even experienced doctors can take a page from medical students. It's the taking the history that matters. Everything else we do, the physical exam, lab work, and imaging tests are tools and not the truth.

Want to know, one other time a patient lies?

When you see an otherwise healthy young man in the office who simply wants an annual check-up just to be safe. These types of patients are as common as seeing the Loch Ness monster.

The real reason he's there? His spouse, girlfriend, or significant other for a symptom he's been complaining about but didn't want to see a doctor.

If I don't get to that truth, guess who I'll be seeing next week? The same patient again but with his spouse, girlfriend, or significant other.

Or he's asking about Viagra.

The Best Book on Healthcare Reform (or Surviving It)

2010-12-23T11:49:00.000-08:00

The best book on healthcare reform or surviving it is the The Innovator's Prescription: A Disruptive Solution for Health Care. The decade worth of research spent understanding, studying, and ultimately offering solutions to make the health care system more accessible, higher quality, and affordable is clear. Unlike other books, the authors, respected Harvard Business School (HBS) professor Clayton Christensen, a doctor who also was the Director of Health Care Delivery Policy Program at Harvard Kennedy School Jerome Grossman, and another doctor and graduate of the MBA program at HBS Jason Hwang avoid the traps the plague most other solutions by taking a completely different perspective by looking at other industries where products and services offered were "so complicated and expensive that only people with a lot of money can afford them, and only people with a lot of expertise can provide or use them." Yet convincingly through plenty of examples, it shows how telephones, computers, and airline travel moved from only accessible to those with the resources to become available and affordable to all.

The book tackles every aspect of health care and asks how will those in health care be disrupted and subsequently surpassed by other providers which deliver care that is more convenient, higher quality, and lower cost.

What will hospitals need to do as increasingly more surgical procedures are performed in high volume specialty hospitals?

How will doctor practices sustain themselves as new diagnostic tools and research makes the identification and treatment of problems more precise that nurse practitioners with clear protocols can deliver care previously required by physicians?

What mechanisms exist to streamline and integrate the various players of health care (doctors, hospitals, purchasers, insurers) so that all are focused on the benefit of wellness and outcomes of patient care rather than maximizing each of their own financials? (Hint: large employers will integrate health care and others will only purchase care delivered by integrated healthcare delivery systems).

What should medical schools do to prepare the next generation of doctors as current training is steeped in tradition, relevant a century ago, but woefully inadequate for the future?

How should pharmaceutical, medical device manufacturers, and diagnostic equipment makers position themselves for the inevitable changes that will affect them the same way previous leaders in other industries were overtaken by competitors and disruption?

How must the reimbursement system and regulators adapt to foster the innovation to make these changes occur?

If there is anything close to a crystal ball on what health care delivery will look like in the United States that will be increasingly affordable, higher quality, and accessible to all, this is it. They authors have convincingly demonstrated the likely path as well as indicated why a single payer nationalized system will stifle the innovation needed to improve our health care system. Those who wish to succeed in the new world of health care as predicted by this comprehensive and thoughtful analysis would be wise to consider this book.

Elizabeth Edwards, Breast Cancer, and Mammograms - Her Death a Failure of Healthcare System.

2010-12-12T09:54:00.000-08:00

Elizabeth Edwards died recently of breast cancer at 61, leaving behind three children, Cate (28), Emma Claire (12), and Jack (10). Described by her eldest daughter as intelligent, humorous, and witty, I'm fairly certain that she would not have wanted to leave her children at such a young age. Yet, in November 2004, shortly after the presidential election, she announced to the public that she had discovered a breast lump, which ultimately was diagnosed as cancer. She admitted shortly after her diagnosis that at age 55 that she had not been screened for breast cancer with a mammogram for about four years.

Which is why the recent report from the San Antonio Breast Cancer Symposium, done annually in December, is particularly worrisome. The study period between 2006 to 2009 found these screening rates to be lower rates than the past. Only 50 percent of women eligible to be screened for breast cancer actually did so. That number improved slightly to 60 percent with women receiving two mammograms over a four year period.

In other words, 40 percent of women, who should get mammograms, aren't getting them.

Just like Elizabeth Edwards.

Is it personal choice? A cost issue? Or lack of time? Lack of understanding? While experts debate, I'll tell you.

It's a lack of time and lack of understanding. Everyone is incredibly busy. Given a choice, patients will do the right thing if they are nudged to do so. In fact, they want doctors to help guide them to the correct choice. Elizabeth Edwards certainly as a mother and professional woman had the financial resources and intelligence to know the importance of annual mammograms starting at age 40, yet didn't do so. Perhaps she didn't think she was at risk. Maybe she was focused on her children and husband and didn't care for herself as much as she should have, a common trait for many mothers.

The question is was she reminded of her options? If she was a patient in my practice, she would have benefited from a team effort that constantly worked to keep her healthy. At every office visit, whether with a primary care doctor or a specialist, every patient at every check-in received a personalized checklist that is age appropriate. Ms. Edwards would have seen on her checklist that she was overdue for her mammogram.

To make it incredibly easy to get it done, all of the medical offices that her doctors work at have a radiology department with mammogram machines. To make it even easier, patients can walk-in to have them done. No appointments needed. No paper work required. She simply would have finished up with her doctor, checked in with radiology, and had her mammogram.

If by chance she was busy and otherwise healthy and hadn't seen a doctor face to face, but was overdue then she would have been notified by mail at least three times to remind her of that fact. A team of healthcare providers use the electronic medical record to find which women are overdue, contact them, and then check again to see if the mammogram was done. If after a few attempts if there still was no response, her primary care doctor would get a message to call her, just to make sure she fully understood the choice she was making. If she still declined, while that would not be the medically advisable, her decision would be respected. After all, she is an adult and would have been fully informed about the pros and cons of her decisions.

It's likely, however, that instead of a four year absence, she would have opted for a mammogram. It would have shown an abnormality months before she actually felt a lump. Chance of recurrence is much less when breast cancer is caught at a non-palpable stage.

Despite all of the advances in oncology and chemotherapy treatments, the biggest decline in breast cancer deaths over the past 25 years was due to mammogram screening. Though the new healthcare reform bill which make preventative services like screening for cancer free, that isn't enough. If people are too busy to remember, much like doing the right thing for retirement planning, they won't do what is in their best interest, even if it is what they would have done if they only had time.

In other words, it isn't about the individual as much as enabling the individual to do the best for herself by designing the system to get the best outcome. It is true in retirement planning and automotive and road design as it is in healthcare.

I don't believe that if she had such a healthcare system in place to help her stay healthy and well that her life would have ended this way. While the system I describe exists today in California, where I work, and our breast cancer screening rates are far far better than the study quoted at the San Antonio Breast Symposium, any death that was too soon and preventable in my mind is a failure. A failure not of the individual patient, but of the healthcare system.

Perhaps that is why she was a health care activist.

Although I've never met her, I am certain that given a choice had she had the healthcare system around her which optimized her chances for the right decision, she would have never wanted to leave her children at such a young age. The absence of such a system is the true tragedy.

My thoughts are with her family, friends, and most especially her children, Cate, Emma Claire, and Jack.