Recently in Health / Medicine Category
I am at the First Stanford Symposium on Bedside Medicine, and we have the world's leading experts on the diagnostic examination gathered here. It is a small group who still believe there is value in examining the patient, even in this era of imaging and technology.An anthropologist from Mars looking at our hospitals might conclude that the 'work' of medicine takes place in rooms far removed from the patient, typically in front of a computer screen. The actual patient and the person-hood of the patient is pushed to the margin of medical attention while the 'iPatient', the virtual patient rules.
Last night we talked about the ritual of the exam, and how important that ritual is. Rituals are about transformation, and the careful exam has all the elements of ritual, including a sacred space, a ceremonial garb (white coat and patient gown), a routine that is mysterious to the patient and includes disrobing and touch (which in any other context would be assault). Rituals are about transformation (think wedding, baptism etc) and this ritual when done well, is transformative, it establishes the physician-patient bond, it recognizes the body of the patient (the soma as opposed to the image of the body), and it is therapeutic, particularly in chronic disease, where the ritual repeated at every visit conveys to the patient that we are with them on the journey, we will not abandon them.
Everyone agreed to this aspect of the exam, the importance of ritual. Then why is it that we so rarely emphasize the importance of the ritual when trying to defend and preserve what is a threatened craft? I think it is because this ritual (like love, steadfastness, loyalty, courage) is not easily measured, and in a medical world that seems to be ruled by psychometricians, if it ain't measured it doesn't exist.
But hope springs eternal, and this little group is determined to bring about change.
(Photo: Flickr User mynameisharsha)
The unfortunate politicians who have braved town hall meetings in recent days to talk about health reform seem to have been taken by surprise by the vitriol and volume of the push back. Yes, I know the audiences were marshaled and recruited to shout down the speakers but still the passion on display was genuine and not in the least surprising to me. What the President and our politicians should have known is that our personal health is the one arena of our lives (the other being our love lives) where reason and logic get thrown out of the window. Talk about our health and suddenly our education and civility vanish and we are a mob waiting to be ignited. The incredible thing is you can just as easily incite us to march for reform as you can against reform. All that matters is what button you push. Read More
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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.
I had the pleasure of being in the East Wing of the White House on Wednesday, one of about 160 people in the audience as President Obama appeared on national television, fielding questions about health care.
It was my first look at the President at close quarters. I came away with the impression that the President was possibly the most knowledgeable person in the room when it came to the current health care crisis. That's no small thing given the people who were there. We have had Presidents whose understanding of issues seemed confined to the precise talking points prepared by aides in briefings. This President knew his material well and was improvising as smartly as a jazz pianist, in response to questions.
The other thing I sensed was the President's tremendous passion for this cause. If there is something more important on his agenda, I don't know what it is. What also came across is that compared to everyone else who was there (physicians like me, the CEO of Aetna, the head of the AMA), the President was probably the only one whose interests in the health care debate were not self serving. His sole motivation seems to be to head off disaster, which seems inevitable if reform does not take place.
An important moment for me personally came when a young woman asked the President the very question that I had been prepared to ask. She wanted to know why we could not emulate the example of other advanced democracies that manage to cover all their citizens for about half what it seems to cost us. The President's answer was revealing; he pointed out that most of those countries had a one-payer system whereas we in America, "...have an employer based system that has grown up over decades. For us to completely change our system, root and branch, would be hugely disruptive and I think would end up resulting in people having to completely change their doctors, their health care providers in a way that I'm not prepared to go. This is one-sixth of our economy. I think that we can build on what works, fix what's broken, and still have some substantial money."
The obstacles in the President's way are considerable: 1) people and businesses who are profiting hugely from the status quo; 2) a general fear of government interference; 3) fear in Congress about the amount of money to be spent on health care reform and finally, 4) the fact that legislators who have to make change happen often serve the interests of the people who gave them the most campaign money--pharma, insurers, organized medicine. These contributions are what taint our political process--call it first world corruption.
I got back to my hotel room at 10pm, just as the session (which had been recorded "live to tape") was finally being aired. I was surprised to see that one commercial shown during the health care debate was on behalf of "Patients United Now"--a group I know little about. The ad was sowing seeds of fear by having a Canadian patient talk about the difficulties of that system. They couldn't wait to hear what the President had to say it seems.
Oh yes, and the other thing on television competing on the other channels was the news of Governor Sanford's whereabouts. As to that . . . less is more.
Our costly health care system is unsustainable for doctors like Michael Kahn in New Hampshire, who, as he puts it, spends 20 percent of each day supervising a staff explaining insurance problems to patients, completing authorization forms, and writing appeal letters; a routine that he calls disruptive and distracting, giving him less time to do what he became a doctor to do and actually care for his patients.
The President's speech even quoted Newt Gingrich:
As Newt Gingrich has rightly pointed out, we do a better job tracking a FedEx package in this country than we do tracking a patient's health records.
The speech reminded me of a conversation a few days ago with a close friend who said casually, "Face it, Abraham, medicine is corrupt." I paused. I sputtered. I was about to say something. But I shut up. I shut up because (as the President explains) whether I like it or not, I am a beneficiary of a system of :
. . incentives where the more tests and services are provided, the more money we pay. And a lot of people in this room know what I'm talking about. It is a model that rewards the quantity of care rather than the quality of care; that pushes you, the doctor, to see more and more patients even if you can't spend much time with each; and gives you every incentive to order that extra MRI or EKG, even if it's not truly necessary. It is a model that has taken the pursuit of medicine from a profession - a calling - to a business.
We can quibble on the ways the President proposes to fund the changes he proposes, but I don't think we can quibble on the moral imperative to change the way we do business. As the President says,
"You entered this profession to be healers - and that's what our health care system should let you be."
(For another take on the speech from a thoughtful physician who also happens to be in New Hampshire, see KevinMD.com)
What always strikes me when I come back to being on the in-patient wards is the mountain of data that exists on each patient. It's a surprise every time, a feeling analogous to revisiting Bombay or Madras after years of being away and finding that a city you did not think could get more congested, has done just that.
For example, if we admit to our service a patient who once had a transplant in our hospital, that guarantees records from many prior admissions--a veritable encyclopedia in the computer. Add to that everything generated in the hours that they were in the emergency room before making their way up to the ward (ER attending's note, blood tests, imaging studies, nurses' notes, consultants' notes) and you find that the real patient under the sheets is dwarfed by the labels and data that precede them. The task of sifting through that pile of information seems to get more challenging every year.
A few days ago my brother sent me a paper quoting the psychologist Herbert Simon who in 1969 lecture said:
"the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it."
Simon anticipated by 40 years the issue I've been wrestling with this week: is the information extant per patient, the sheer mass of it (measured not in stacks of papers, but in searchable gigabytes) at times detrimental to patient care? Data = mass = gravitational pull so that any of us opening a patient file enters a force field and find ourselves sucked in. For the interns' generation which has grown up on computers, the force is perhaps stronger or the nature of that kind of work is familiar.
Being a good doctor does involve carefully studying the old records. In the old days, one had to make an effort to go to the file room and get the dusty old charts, or if they were not there, track them to the cubbyhole where they awaited someone's signature. There was virtue in the effort simply because less conscientious physicians might not bother and they therefore might duplicate tests that needn't be done, or might miss the boat altogether in terms of what ailed the patient.
Nowadays, as I watch us all scour the digital records (no dust to inhale, no rubber bands that snap in your face) the task is so much easier. The new issue is that the information can detract and distract; we can wind up sitting too long in the chair staring at it. To paraphrase T.S. Eliot, knowledge can get lost in information, just as wisdom can get lost in knowledge.
On several occasions this week, I've felt that my time at our patients' bedsides, examining them (because only the exam can tell you if there is pain and if it's better than yesterday, and they seem more or less anxious today), learning who exactly they are, getting to understand what they want and most importantly listening to what they can tell us about their body, has helped make sense of confusing test results and contradictory stories piling up in the computer (and they pile up thanks to the cut-and-paste function which perpetuates misinformation).
So, in response to my brilliant student who is performing at the very highest level but who asked me this morning how he might get even better on the wards, I quoted Herbert Adam's words --poverty of attention-- which is going to be my new mantra, and I unveiled my Special Theory of Attentivity:
I suggested to him that Ac and Ap should at least be equal; preferably we should err to much more of Ap--time at the bedside. I suggested that he try to meet the patient in the flesh first before he shook hands with the patient's data; I suggested he work on getting as much as he can from listening to the patient, from sounding the body and only then turn to the computer. It's the opposite of how we now do things. I told him he might be humbled by what the records will show him he has missed, and he might be proud of what he has found that is not in the record or is wrong in the record.
I hope he'll find that his interaction with the patient will feel different, truly new because he will approach them without bias or labels.
Let's see what he reports. I have no doubt we will both learn something.
Abraham Verghese
