Airport security and hamster wheels: analogies for American primary care

Since having children (two, ages 3 and 1), I've dreaded going through security screening at airports. With carry-on bags, collapsible stroller, car seat, and various prohibited-unless-you're-traveling with-an-infant beverages in tow, it always seems to take an eternity to disassemble ourselves (including removing my toddler's infant size 4 Dora the Explorer sneakers, in case they may be harboring a terrorist weapon) and reassemble everything correctly on the other side of the metal detector before an officious TSA employee, or worse, a fellow passenger, informs us that we're taking too long and are holding up the long line behind us. In our recent holiday trip overseas, I prematurely congratulated myself for managing to move all of our luggage off the belt in a timely fashion, only to be admonished by a TSA employee that our bags were blocking the exit to the departure gates and needed to be moved ASAP. Just 30 seconds to replace our boarding passes in my backpack? Out of luck. Move it along, buddy.

What saved me in this case from having my usual post-security screening explosion (aside from my wife's saying that I take these things much too seriously) was the sudden insight that this undignified process is a near-perfect metaphor for the current state of affairs in American primary care. Primary care clinicians in the U.S. are facing mounting pressure to see patients with increasingly complex medical conditions in less time, for less money, with administrative hurdles that seem to worsen every year. Despite the ample intellectual challenges and emotional rewards of "uncomplicated" primary care, it's no wonder that so few medical students are choosing careers in family medicine, general internal medicine, or general pediatrics. Try as we might, we can't find a way to get our luggage off the belt without making patients, payers, or specialist colleagues unhappy (these days, published scientific papers bemoaning the inability of primary care clinicians to detect this or that rare or pseudo-condition are a dime a dozen).

Another metaphor for the ills of primary care medicine is the hamster wheel, first proposed in the British Medical Journal in 2000:

Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still. ... In the government sponsored, single payer system in Canada; the mandatory insurance systems in Japan or continental Europe; or the managed care systems in the United States, doctors feel that they have to see more patients to maintain their incomes. But systems that depend on everybody running faster are not sustainable. The answer must be to redesign health care.

Of the many innovative proposals put forth in the past decade to redesign health care (a few of which I've mentioned in previous blog posts), the one that seems to be gaining the most traction is the patient-centered medical home, an integrated, team-based approach to providing a set of essential health services to every patient. This new model of care is both a return to family medicine's roots of caring for the "whole patient" with several contemporary ideas added in, including health information technology, patient registries, and proactive outreach to patients with chronic diseases. The current health reform bills being debated in Congress, while not doing nearly enough to support the medical home, are a step in the right direction.

So whether you prefer the metaphor of airport security or the hamster wheel, now is the time to become engaged in the movement to shape health reform in order to banish these metaphors once and for all.

The best recent posts you may have missed

Every other month or so, I post a list of my top 5 favorite posts since the preceding "best of" list on this blog, for those of you who have only recently started reading Common Sense Family Doctor or don't read it regularly. Here are my favorites from September and October:

1) Why you should just say no to "routine blood work" (9/13/09)

2) Public option or no public option: that is not the question (10/27/09)

3) Why "patient centered" health care isn't the norm (10/5/09)

4) The "single payer" should be you (9/17/09)

5) Primary care: no next generation? (9/21/09)

If you have a personal favorite that isn't on this list, please let me know. In the future, if enough people are interested, I may set up an "audience vote" function to choose the most popular posts. Happy Thanksgiving!

Guest Blog: Thanksgiving: Visiting My Brother on the Ward

Peter Schmitt is the author of five collections of poems, including Renewing the Vows, in which the following poem (first published in the Bellevue Literary Review) appears. You can find more information at his website, http://www.schmittpoetry.com/.

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THANKSGIVING: VISITING MY BROTHER ON THE WARD

Behind the thick, crosshatched glass of the cruiser,
my brother, back for the holiday, breathes
more slowly. A phalanx of uniforms
cloaks the open door, murmuring to him
where he sits. The carving knife is somewhere
out of reach, none of us so much as scratched.
Inside, the bound bird cools on the butcher block.

Later that night I move through many doors, each
locking behind me, each inlaid with the same
heavy glass as the squad car. Through the last
I see my brother's face, fixed as on a graph,
ordinate, abscissa. When he sees mine
he retreats from the common room to his own,
a bare cell he shares with a narrow bed.

He will not speak to me, at first. His fingers
move in perpetual chafe, like a mantis,
his lifelong nervous habit, the edges
of a newspaper shredded on the bed.
This time, his eyes say, we have betrayed him
as never before. This time, he seems to say,
he cannot find a way to forgive us.

At last I persuade him to join the others
finishing the meal, their plastic utensils
working the meat, their low voices broken
by stray whoops of inappropriate laughter.
We sit, though, in a separating silence,
my brother's hand already eroding
his napkin, eyes distant with medication.

If only he were faithful to himself
and took his daily pills ... But what is the point
of such a constancy when the world itself
has so profoundly turned away? As tonight
I will leave him here, leave all of them here,
the psychotics and depressives, my brother,
to lie in their beds and stare at their ceilings,

and I know that for at least this visit
he will not come home, where our parents now sit
in darkness, their faces streaked and damp. And when
we drive him to the airport, an unmarked
police car following as an escort,
he might be a foreign dignitary
bearing developments back to his country ...

For now, though, it is just two brothers, beneath
a glaring bulb. The expression on his face
would ask, Have you gotten what you came for?
And again I have no answer for him.
But there, at the floor of the bed, all around
the room, are crumbs of paper, as if he were
leaving a trail by which he might be found.

- Peter Schmitt

Cancer screening and obstacles to health care reform

This week's update of the U.S. Preventive Services Task Force's recommendations on screening for breast cancer have, to quote a headline from today's Washington Post article, stirred up a "tempest" of public reactions ranging from cautious praise to outright condemnation and patently uninformed accusations that the new recommendation against routine screening in women age 40 to 49 years was motivated by cost-saving considerations. A mere 15 months ago, a similar response to this Task Force's recommendation against screening men age 75 years and older for prostate cancer inspired me to write the piece below.

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The message of the new recommendation was surprising to many people – that the blood test so commonly used to screen men for prostate cancer creates a situation in which uncertain benefits are balanced against certain harms. An unreliable screening test (the prostate-specific antigen, or PSA), combined with an unreliable confirmatory test (the biopsy), combined with the understandable desire of most men to remove any traces of cancer from their bodies, lead to unintended adverse effects ranging from anxiety to surgical complications to death. In some men between the ages of 50 to 74, these adverse effects may possibly be worth the potential benefits; in men aged 75 and older, they are almost certainly not.

Amid the subsequent avalanche of angry responses that played out in newspapers, blogs, and other public forums, the charge that hurt the most was that the guideline authors and the "faceless government bureaucrats" (including me) who supported their work couldn’t possibly understand what it was like to be or care for a patient suffering from prostate cancer. It hurt the most because I did. I remember only too well a patient – whom I’ll call Kendall – from my residency training in Lancaster, Pennsylvania, better known as the heart of the Amish Country. Although Kendall wasn’t Amish, he hadn’t seen a doctor in decades when he was hospitalized with bone pain at the age of 75 and found to have advanced, metastatic prostate cancer with a PSA level of more than 5000 (by comparison, a PSA of greater than 4 is commonly considered to be suspicious for prostate cancer).

By the time I met Kendall, however, he had responded dramatically to a course of palliative therapy and been discharged from hospice care. At his outpatient visits, he was a man of few words but big gestures. I remember how he always stood and clasped my right hand tightly in both of his as we were concluding an appointment. “See you in a few months, doc.” Later, as the cancer returned and he began taking strong pain medication, he became one of my favorite home visit patients.

For Kendall, the end came surprisingly quickly. During my 3rd year internal medicine rotation, I was paged by his hospice nurse with the news that he had become combative and disoriented. I met him in the ER and tried to soothe him as we did blood tests to confirm there was nothing we could fix. Sooner afterwards, he was transferred to an inpatient hospice, and died a few days later.

Could Kendall’s life have been extended by PSA testing? It’s hard to know. I tend to doubt it, given the aggressiveness of his cancer, but it’s possible. And I admit that while working on a recommendation that advocates for stopping testing at age 75, he came more than once to my mind. Supposedly guideline panels only consider benefits and harms to populations, not individuals. That statement couldn’t be more wrong. In my mind, thinking about populations means trying to maximize the benefits, and minimize the harms, for as many individuals as possible.

I probably should have been prepared for the outpouring of negative comments about the recommendation and those responsible for developing it, including me. Like screening tests and treatments, recommendations inevitably have adverse effects. Prostate cancer affects so many men in the U.S. that it naturally incites strong passions, with or without requisite scientific knowledge. But to the charge of being a faceless, cold-hearted bureaucrat without first-hand knowledge of the suffering this disease causes, I respond that it is possible to maintain one’s clinical perspective, and to care deeply about what happens to individual patients, while also making decisions that affect more than the patient in the room. Indeed, the lesson that I might have learned from Kendall’s story is that indiscriminate testing is always better – and that would have been the wrong lesson.

Conscience and health care reform: a personal view

A little over a year ago, the DMC Pharmacy opened amid great fanfare and some mild protests in an otherwise nondescript shopping plaza in Chantilly, Virginia. What makes this particular pharmacy unlike other local pharmacies (besides its nonprofit status) is that it is one of only 7 pharmacies in the nation that has a "pro-life mission," declining to stock condoms, contraceptives, and "morning after" pills. DMC Pharmacy's parent organization, Divine Mercy Care, includes the Tepeyac Family Center, the Ob/Gyn practice that delivered my son.

My wife and I chose Tepeyac - easily an hour's drive from our home - over dozens of geographically closer practices because we were seeking physicians who practiced medicine that was consistent with our faith. They would understand, for example, why we immediately declined the triple screen test despite the increased risk for birth defects associated with my wife's age. Under absolutely no circumstances would either of us consider an abortion, a conviction rooted in our mutual faith and my personal experience in medical school, when I observed firsthand, with increasing horror and revulsion, several second-trimester abortions during my obstetrics rotation.

The recent passage of the House version of the health care reform bill included language that has come to be known as the Stupak amendment (after the representative who proposed it), which instantly became a lightning rod for praise from some quarters and criticism from others. It is clear that the House bill would not have passed without the amendment (supported by most Republicans and 64 Democrats), which essentially forbids federally funded or subsidized insurance from paying for abortions. Nonetheless, many in Congress have loudly declared their intent to remove it from the final legislation, or failing that, seem willing to let this incarnation of health care reform die so (not to put too fine a point on it) unborn babies can go on dying as well.

I recognize that my describing abortion in such language may be viewed as inflammatory by some. On the other hand, I don't believe that we can honestly tackle these thorny issues of conscience, and, especially, of faith, in health care without being painfully direct about it. Unlike some pro-life activists, I don't dispute the legal right of a woman in the U.S. to have an abortion for any reason - what I, and apparently a majority of congressmen and women, dispute is their right to have one using my tax dollars.

While I sincerely hope that the current health care reform effort, imperfect as it is, won't be derailed by people on either "side of the aisle" seeking to score ideological points, the point I'm making is that for me and many others, ideology isn't the issue at all. As a family physician who has worked in the underserved communities of Washington, DC, I understand more than most that the lack of access to or ability to afford quality primary care is itself a profound moral issue, and it pains me to have to balance my desire to give all people in the U.S. a 21st century health system with my conviction that that health system neither condone nor encourage a medical intervention that is unique in ending, rather than protecting, life. There needs to be another option - there must be a better way - and I implore all who are reading to seek it while there's still an opportunity to do so.

Guest Blog: Anatomy Lesson

Nellie Hill's poems have appeared widely in literary journals in print and online. "Anatomy Lesson," first published in the Bellevue Literary Review, also appears in My Daily Walk (Pudding House, 2008). Nellie has an acupressure practice in Berkeley, California.

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ANATOMY LESSON

To understand the heart
you've got to memorize arteries, vessels,
and which goes where, which is red
and which is blue, what's likely to pop open -
is it in your head or behind your wings
or the one down low in the snake path
of food that winds around the tangle
of bladder, liver, spleen.

Kidneys, too, the root of the whole thing,
the seat of life - your chi,
that thrust of breath from the small of your back.
Guard it, especially in wind with damp heat rising
and those sudden storms that cool
afternoon sweat from your forehead
before time works its way in
to where thoughts become memories or dreams.

You see? At last you understand,
anatomy stacked like a ladder from your toes
right up to your knees and elbows
and each footstep of a rib
until you're in your head again
with words for every thing, each one.

- Nellie Hill

When less health care makes sense

One seemingly contradictory notion in health reform, which generally aims to improve everyone's access to health care services, is that in most medical situations, less is actually more. I've written previously about why it may be better to "just say no" to blood tests that you don't really need. Recently, Forbes.com published an article that highlighted several medical tests or procedures that doctors commonly provide, but probably have no health benefit compared to no treatment or safer, less expensive therapies. I list these below, with links to some relevant scientific articles and guidelines:

1) Vertebroplasty for spinal fractures from osteoporosis

2) Minimially invasive ("robotic") surgery for prostate cancer

3) Continuous fetal heart rate monitoring during labor

4) Coronary artery disease screening

5) Excessive high-tech (CT) imaging

6) Newer drugs for schizophrenia (remember my mental health success story? That patient likely would have done just as well taking an older, cheaper drug with fewer side effects)

7) Hospitalizations for syncope (fainting spells)

8) Spinal fusion for back pain

9) Knee arthroscopy for arthritis

The Forbes article suggests that as much as $650 billion of the United States's $2.5 trillion annual health care expenditures are probably unnecessary; other experts, such as the New America Foundation's Shannon Brownlee, suggest that the tab could be even more. (If you want to read more about this issue, I strongly recommend her book Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.)

If these therapies don't work, then why do doctors keep providing them, and insurers, for the most part, keep paying for them? Are they just not familiar with the evidence? Do they have some ulterior financial motive? Or is there something else going on here? What do you think?

Evidence plus intuition equals good health care

When I was in residency, one of my favorite faculty members kept a running list of "medical myths," things that most doctors believed to be true but in fact had been disproven (often long ago) by controlled experiments. Many of these myths were held by surgeons; for example, 1) patients with acute pancreatitis should not receive morphine for pain control because it will only worsen the problem (actually, it doesn't, and the most commonly used alternative, meperidine, provides less relief and more adverse effects) and 2) patients with suspected appendicitis should not receive any pain medication until they've been examined by the surgeon, or the classic abdominal examination signs will be "masked" by the medication (actually, there's no evidence that early pain relief worsens surgical decision-making). The British Medical Journal annually publishes critical reviews of popular medical myths; apropros for the season, the 2007 edition found that Thanksgiving turkey doesn't make you any more sleepy than chicken or beef.

Medical myths are obstacles to health care reform because at best, they waste money, and at worst, they lead hospitals and physicians to provide "care" that is actually harmful. When confronted with evidence that they are doing things to patients that are not supported by scientific studies, many physicians claim that the results of the studies don't apply to their patients - which can occasionally be true, but often isn't, as Newsweek columnist Sharon Begley recently wrote:

Of course, practicing medicine should not be like following a cookbook recipe. If doctors conclude that an individual patient is very different from those in studies that showed a particular treatment to work, they might be justified in treating that patient with something other than the EBM-supported drug or procedure. The trouble is that too many doctors think they have exceptional patients.

To this, I would add that many doctors just consider themselves to be exceptional. Last week, following the publication of a study in the New England Journal of Medicine showing that the older technique of coronary artery bypass surgery (CABG) with a heart-lung machine actually produces superior outcomes than the newer technique of "off pump" CABG, cardiac surgeons who perform the newer (and apparently inferior) technique were quick to tell reporters that the results of this rigorous study didn't apply to them. If you or a relative need any type of heart procedure in the future, I'd advise avoiding those doctors like the plague (or a heart attack).

Good things happen when health care follows the evidence. In last weekend's New York Times Magazine, David Leonhardt described how Intermountain Healthcare, a nonprofit health system serving Utah and southeastern Idaho, has successfully adopted evidence-based protocols for 50 clinical conditions that have resulted in dramatic declines in bad patient outcomes, including deaths. These protocols are continuously assessed and improved, and doctors who don't get with the program (usually those who believe their medical intuition to be superior to EBM) are confronted with data showing that their patients do worse than average. In my mind, the next step in health care reform is to apply this process on a national scale, in order to convince the leaders of other hospitals and health systems (only 1% of whom rate their care quality as "below average") that they're not exceptional, either.

Guest Blog: I Want to Work in A Hospital

Cortney Davis is the author of four poetry collections, most recently "Leopold's Maneuvers," winner of the 2003 Prairie Schooner Poetry Prize. She is co-editor of two anthologies of poetry and prose by nurses, "Between the Heartbeats" and "Intensive Care," and is the author of two non-fiction books, "I Knew a Woman: the Experience of the Female Body" and "The Heart's Truth: Essays on the Art of Nursing." A nurse practitioner, she is the poetry editor of the literary journal Alimentum: the Literature of Food. Her website is http://www.cortneydavis.com/. The following piece was first published in the Bellevue Literary Review (edited by physician-author Danielle Ofri, who also wrote a guest blog last month).

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I WANT TO WORK IN A HOSPITAL

where it's okay
to climb into bed with patients
and hold them -
pre-op, before they lose
their legs or breasts, or after,
to tell them
they are still whole.

Or post-partum,
when they have just returned
from that strange garden,
or when they are dying,
as if somehow because I stay
they are free to go,
taking with them
the color of my eyes.

I want the daylight
I walk out into
to become the flashlight they carry,
waving it
so God might find them
as we go together
into their long night.

- Cortney Davis

Doctors' conflicts of interest can harm your health - Part 3 of 3

It's football season, so I begin this concluding post on the problem of doctors' conflicts of interest with an admittedly farfetched football-related scenario. Let's say that NFL commissioner Roger Goodell has hired you to make sure that the ceremonial coin used for the Super Bowl coin toss is a fair coin. Your testing procedure consists of flipping the coin some number of times and then tallying the heads and tails. If you flip a fair coin enough times, you're likely to come up with a roughly equal number of heads and tails. But what if you secretly work for a rival ceremonial coin-making company that has an interest in getting the NFL to switch business partners? To make it seem as if the coin isn't fair, you decide to selectively report all of the times it comes up heads, but only 20 percent of the times it comes up tails.

Medical journals are all too familiar with this phenomenon of selective reporting. In the case of research, it occurs when clinical studies funded by commercial interests are more likely to be submitted (and therefore, published) when they show a positive effect of the drug or device, and less likely to do so when the results show no effect. Later on, when a trusted international scientific review group such as the Cochrane Collaboration decides to summarize the results of all studies on this drug or device, publication bias may lead them to draw erroneous conclusions about its true effectiveness.

This is not a small problem in real life care situations. Take depression, for example. The introduction of the drug class of selective serotonin reuptake inhibitors in 1987, beginning with the drug Prozac, in many ways revolutioned the treatment of depression and brought its diagnosis and management into the realm of primary care. Recently, however, serious questions have been raised about the true effectiveness of these drugs, based on the results of a 2008 study published in the online journal PLoS Medicine that analyzed the results of all published and unpublished results submitted to the U.S. Food and Drug Administration and concluded surprisingly that for all but the most severely depressed patients, new antidepressants were no better than placebo pills. This finding doesn't necessarily mean that "the drugs don't work" - since effects were averaged over all patients who took the drugs, some people's depression may have improved, some may have stayed the same, and some may have gotten worse. But it does mean that the benefits of antidepressants have been systematically exaggerated in the medical literature, thanks to selective reporting.

How are medical editors and others fighting back against this now widely recognized problem? In 2004, the International Committee of Medical Journal Editors began requiring that investigators register clinical trials on publicly accessible registries such as Clinicaltrials.gov as a precondition for publication. Earlier this year, this group went a step further by establishing a uniform format for conflict-of-interest disclosures, in the hope of making it more difficult for industry-funded authors to "forget" to inform journals about whom they're working for. Finally, two of the health reform bills pending action in the House and Senate would require all drug and device-makers to file annual reports to the government, to be made freely available online, on payments to physicians and health organizations. Which gives me and all of those who are hoping that health reform passes soon in some form another reason to do so.

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Note: if you missed the first two posts in this mini-series, you can access them here:

Part 1 - Drug Reps and Ghostwriting

Part 2 - Conference Exhibitions and Dishonest Disclosures