July 2009 Archives
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I attended a wonderful presentation a few days ago by Ajit Varki, a physician and scientist at the University of California San Diego and head of the Center for Academic Research and Training in Anthropogeny. That word, "anthropogeny" was a new one for me. It means, 'explaining the origin of humans, or 'the science or study of human generation.' Varki's long standing interest in sialic acid receptors that are plentiful in all our cells led him to discover that we lost one variety of that receptor some time ago when we diverged from our nearest relatives, the apes.
The work of Varki and his colleagues is particularly helpful in the gene versus environment debate. A spate of recent articles have pointed out that the human genome project hasn't as yet yielded the treasures that were promised. Our science fiction fantasy was that we'd map your
genome, and predict that on a Tuesday in September in 2022, you would
wake up with a heart attack or a brain tumor (and presumably there were thing we could to help you avoid that fate). It turns out that even though we now have identified many areas on the human chromosome linked to diseases like diabetes, they simply are not very useful to predict that the patient will get diabetes.
For example, if I see an overweight patient walk into my office, that sight alone is
a better predictor of their risk for diabetes than any genetic test I
might order. If a pack of cigarettes shows in his pocket and his finger nail is yellow, I know a lot about his risk of sudden death from heart disease. I must say that as a clinician, this is somewhat reassuring, the notion that you still have to use your eyes and senses and earn the patient's trust to learn the kinds of things that may have put him or her at risk for various illnesses. It also says we have much to learn about the environment and its influences on us.
Dr. Varki's group suggests that even 'nature versus nurture' is too simplistic a debate, and that we as humans evolved because of a dependence on learned behaviors and social interactions that may have been advantageous. It may be that even things like breastfeeding among animals are learned behaviors and are not hard wired! His work makes for fascinating reading and it would be folly to try to summarize.
As I was preparing this piece, I read in the NY Times about a bear named Yellow-Yellow in the Adirondacks who has managed to get past a bear proof food container that stymies all other bears. Surely this learned behavior will give Yellow-Yellow a survival advantage if that becomes the only source of food available. The big question is can she and will she teach it to her fellow bears, or to her mate and to their progeny? The fate of the universe rests on such questions.
It used to be you could look into the crystal ball and paint a picture for them of what their life would look like when they were done: it used to be that if they chose primary care, they would probably over a lifetime make perhaps 3 to 5 million dollars less than a colleague in a procedural specialty, be harassed with a lot more forms, longer hours, and unless they retreated to a concierge practice where they set a high dollar bar for admission to their practice, they would be very busy.
On the other hand, if they picked dermatology (and I love dermatology, and find it an intriguing discipline), they could count on a good lifestyle (very few dermatological emergencies), they would do lots of procedures, and make a healthy living. The same was true for ophthalmology, radiology--all very competitive disciplines for students to enter.
But what if:
- You get paid only for managing disease, for caring for a stable of patients--in other words, what if there is no fee for service? (By the way, Massachusetts is bravely going this route.) Doing more procedures then will cost you money, not mint money. Suddenly, many procedure based specialties don't look so hot.
- What if Medicare or insurers stopped paying for MRIs, CAT scans and PET scans on an individual basis, but rather only reimbursed for disease management ? The owners of such facilities (who in many cases are doctors) have counted on business continuing as usual and may fold like Chrysler dealerships. Radiology as a career choice might be less attractive.
- What if the physician who cared for the patient, who had formed a steady relationship with the patient over the years, who knew the family, and who was the one who admitted them to the hospital (and then acted as quarterback and kept a close eye on the consultants called in and ensured communication)--what if that individual got paid top dollar? Yes, what if primary care became the plum? Look at who President Obama picked to be Surgeon General: a primary care physician par excellence. There is a message there.
- the House releases its health care bill
- Center for Medicare and Medical Services (CMS) releases a revised physician pay schedule
- The FDA is about to finally get to rule over tobacco companies
07/07/09 9:02 AM
Medical Tests: "Does it work?" matters less than "Does it pay?"
When President Obama speaks about funding health reform, he keeps emphasizing that the money needed to achieve his goals of covering the uninsured, is already in the system:
"Two thirds of the cost would be covered by re-allocating dollars that are already in the health care system, taxpayers are already paying for it, but it's not going to stuff that's making you healthier." (From his appearance on ABC's Prescription for America).
I recently came across a great resource (thanks A.J.!), the California Technology Assessment Forum whose goal is to assess new and emerging technology. It is edifying to look at the list of tests it has assessed, pages of them, and to see how few meet its criteria for a test that improves health outcomes and is safe and effective. And yet the tests are being done and we are collectively paying for them.
Hats off to the President for taking on health care reform, because if you read the CTAF's list of tests that are ineffective, you are also looking at a list of device manufacturers and others who are doing very well on these procedures and tests--every one of them is going to battle him tooth and nail, primarily through their lobbyists in Congress. I sense the President is doing the right thing by taking the message to the public, to us, counting on our sense of outrage to say it is enough.
One of my former students, a brilliant physician who has gone into a rural practice where he does it all--delivers babies, takes care of children, adults, performs procedures--wrote the following to me (tongue in cheek) and I have his permission to use it:
"I justify ordering expensive and unnecessary tests in the following way: It is clear that the current health system is unsustainable. The sooner it collapses, the sooner we can start over again, hopefully with something better. I intend to do my part to bring the system to its knees as soon as possible. (That's only funny because I'm not that way.)"
It's only funny because he truly isn't that way.
Abraham Verghese
