Food for thought on health care reform

"Personal responsibility" is a politically loaded term. In the context of health care, Democrats accuse Republicans of using it to resist the expansion of insurance benefits, while Republicans counter that making comprehensive health insurance mandatory is paternalistic and potentially unaffordable for many people compared to other less costly options. While the fate of the different health reform blueprints recently passed by the Democrat-controlled House and the Senate remains uncertain, I think it's worthwhile to look at other innovative models of financing health care. You might be surprised to learn that two national grocery chains - Whole Foods and Safeway - are right on the cutting edge.

In August 2009, Whole Foods CEO John Mackey stirred up a small controversy by writing in a Wall Street Journal editorial titled "The Whole Foods Alternative to ObamaCare" (though Mackey later stated on his blog that the newspaper editor was wholly responsible for the provocative title) that his company's high-deductible health insurance plan was superior to both the typical employer-provided insurance model as well as government-sponsored insurance plans then under consideration by Congress. How does the Whole Foods plan work? Employees receive up to $1,800 yearly to deposit into a personal health savings account, which they can spend any way they like, paying full price for all medical services. If an employee's yearly health expenses exceed $2,500, catastrophic health insurance coverage kicks in. The lower premiums allow Whole Foods to provide insurance to more employees at lower cost, and employees pay only for the health care they need, rather than the health care that they might need. Personal responsibility in action.

Safeway has taken the philosophy of encouraging its employees to make intelligent health choices to another level. Based on the principle that the majority of health care expenses result from unhealthy behaviors such as phyiscal inactivity, poor diet, and smoking, in 2005 Safeway began offering insurance premium discounts of up to 50 percent to employees who passed a nicotine screening test and achieve weight, blood pressure, and cholesterol goals. Although the program is voluntary, enough employees have joined in that Safeway's obesity and smoking rates are now 70 percent of the national average and their per capita health care costs have not increased for the past 4 years, according to Safeway CEO Steve Burd.

It's not clear if either the Whole Foods or the Safeway insurance plans will survive health care reform unscathed; the Whole Foods plan, after all, is based on catastrophic insurance, which could be erased by any reform bill that requires comprehensive coverage for all eligible persons. And some argue that imposing financial penalties for lifestyle choices is tantamount to discrimination. But both of these examples tell me that personal responsibility for one's health may be one of the missing ingredients in the current conversation on reform.

Guest Blog: Cleft

Jon Neher is clinical professor of family medicine at the University of Washington in Seattle and associate director of the Valley Medical Center Family Medicine Residency Program. He is editor-in-chief of the newsletter Evidence-Based Practice and a frequent contributor of essays on medical education to Family Medicine. The following poem was first published in Pulse Magazine.

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As Caroline was born
the doctor saw
the split
from lip to nose -
purple rimmed,
going down deep -
Deep enough
to hurt
generations.

And the imperfect doctor,
tired of wounds,
tired of divisions,
saw the small
wholeness
Chose that moment
Chose tenderness
Saying simply
She is beautiful.

And the imperfect mother,
tired of pain,
held her child,
touched the tiny,
ragged face
Chose that moment
Chose acceptance
crying softly
She is beautiful.

- Jon Neher

After the health care reform bill passes: what next?

One of the best episodes of the final season of the NBC television series "The West Wing" was a special live (though probably scripted) debate between the Democratic candidate Matt Santos, played by Jimmy Smits, and the Republican candidate Arnold Vinick, played by Alan Alda. At one point, responding to a question about health care, Santos makes a policitically astonishing admission: "I don't like my health plan. I don't think it goes far enough. But it's my plan because I think it's what I can get through the Congress."

It's not hard to imagine that President Obama feels much the same way about the watered-down Senate version of the real-life health reform bill, which cleared a major procedural hurdle last night with no votes to spare and is expected to pass before Christmas. Even administration officials interviewed on yesterday's talk shows expressed only muted praise for a bill that, far from being a "government takeover" of health care, creates no new public insurance option, would still leave 23 million uninsured in 2019, prohibits importing inexpensive medications from Canada, and most critically, does little to control costs. It's a classic compromise solution that pleases neither end of the political spectrum, and, perhaps as a result, is opposed by a majority of the American public.

In spite of all that, this bill is apparently what can get through the Congress, so when the New Year arrives, it will be time to think carefully about next steps - to think about how to turn a bloated $1 trillion insurance subsidy and consumer-protection statute into true "health reform" that provides reliable access to (rather than just coverage for) quality primary care for all and bends the cost curve that threatens our and our children's generations with a staggering national debts as far as the eye can see. I have some ideas, of course, but I'd like to hear what you think the next steps should be.

Guest Blog: The Limits of Medicine

Frances Wu is an assistant director of the Somerset Family Medicine Residency Program in Somerville, NJ. She enjoys teaching, seeing patients and volunteering with the student-run clinic at Robert Wood Johnson Medical School and with the Human Rights Clinic for HealthRight International. "I think that my career in family medicine has given me so much to live for and to write about that I can hardly contain it. I'm working on a novel this year with the impossibly concurrent themes of love, death and the healing power of laughter." The following poem was first published in Pulse: Voices from the Heart of Medicine.

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THE LIMITS OF MEDICINE

I can not change the color of the sky.

The texture of the rain, the distance of a star

must needs be fixed by ancient ritual

unaccepted by our modernity.

I can not change the length of your night.

The number of hours, the days of your life

are set by stern fate, impassive to sighs,

unsympathetic, and cold to your plight.

I can not count the breaths that are left.

Day into day, year into frightened morn,

only you, in your heart can know

the obscurity of the sand that now sifts.

I can not make a single tear move;

Its salt will wend its way to the earth

that calls with an irresistible force,

one that will not soon leave off.

I have been roundly trounced

by movements and thunderings greater

by far than my hand's grasp;

and for their final victory, I apologize.

- Frances Wu

"The health care problem no one's talking about"

As the U.S. Senate inches closer to passing its version of a health reform bill, general internist Thomas Bodenheimer and colleagues from the University of California, San Francisco argue convincingly in the December issue of the Journal of Family Practice that expanding health insurance coverage without expanding of primary care capacity will not lead to improved health outcomes. In addition to a shrinking supply of family physicians, they identify eight additional "barriers" to patients accessing primary care services that must be addressed if health reform is to achieve its potential:

1) Panel size - family physicians, especially those in rural locations, are caring for more patients than they can effectively manage.

2) Capacity - shorter visit times necessitated by large patient panels negatively affect care quality.

3) Distance - many patients live too far from the nearest family physician to access regular primary care.

4) Medicaid/Medicare issues - Medicaid and Medicare fees are often considerably lower than those of private insurers, in some cases, paying physicians less than the actual cost of providing services. Consequently, many practices limit the number of patients with these types of insurances that they accept.

5) After-hours care - is often unavailable.

6) Scheduling - most practices are unable to schedule timely (same day or next day) appointments for non-acute issues.

7) Virtual visits - insurers do not pay for patient encounters via telephone or e-mail, leading to missed opportunities or unnecessary office visits for equivalent services.

8) Troubles with team care - although registered nurses, pharmacists, medical assistants, and other allied health workers that can be trained to perform routine medical tasks and free up physician time, most insurers do not acknowledge (or pay for) non-physician services.

There is no single solution to all of these issues, nor will every solution be right for every practice or every community. But the recent experience of Massachusetts in providing universal health insurance coverage tells us that making primary care more affordable will not make it more accessible; in fact, it is likely to do the opposite. As Dr. Bodenheimer and colleagues conclude, "Unless Americans have greater access to primary care, we fear, the U.S. health care system will undergo significant change without substantial improvement." Regardless of whether a health reform bill passes Congress before Christmas, policymakers must understand that they remain very far from the finish line.

Cultivating new models of health care

I'm a big fan of surgeon-author Atul Gawande, and I eagerly devour each of his new pieces on health and health care reform in the New Yorker. So it was somewhat surprising how difficult it was for me to digest his most recent essay, "Testing, Testing." In a nutshell, Gawande argues that it's okay for the Senate version of the health reform bill to have no "master plan" for controlling the skyrocketing cost of care because health care is to agriculture as family physicians are to family farmers. Huh? This sounds like a bad analogy-type question from the SAT, not a serious argument. But it would be a mistake to dismiss Gawande's suggestion that farming and health care have more in common than one would initially think:

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. ... Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county.

Other notable physicians have recently proposed that primary care practice could be revitalized with the help of a "primary care extension service" analogous to the successful U.S. Agricultural Extension Service. In a plenary address at the 2007 spring conference of the Society of Teachers of Family Medicine, family physician Kevin Grumbach noted:

Just as family farmers were once the nation’s major agricultural providers but are now an endangered species, we know that 75 years ago the majority of physicians in the US were general practitioners, but by the end of the 20th century, family physicians and other generalists had become a distinct minority of physicians. Just as family farmers find that few of their progeny are becoming farmers, we find half as many US medical school graduates are entering family medicine residency programs now as were a decade ago. The dominance of a reductionist paradigm in medicine has devalued the work of primary care and its integrating function for whole-person care.

So what's the solution? How can whole-person care survive in a specialist-dominated U.S. health system? By encouraging lots of experimentation, said Dr. Grumbach, and rethinking the essential functions of a family physician within a health care team. But most practices don't have the time, resources, or expertise to accomplish this practice transformation on their own. Financial incentives should help, but like Drs. Grumbach and Gawande, leaders from the Agency for Healthcare Research and Quality argued in a 2009 editorial that a government-supported extension service would speed the pace of innovation.

Admittedly, it's tough in these times to imagine that a government-sponsored anything could effectively control costs in health care or any other important sector of our failing economy. But regardless of the lack of political will on Capitol Hill, Dr. Gawande's latest article still provides food for thought about the best means of cultivating more effective models of health care in the U.S.

Ignore health reform scare stories

In a previous post, I argued that debates about the inclusion of a "public option" for health insurance in the reform bills taking shape in the U.S. Congress obscured the critical issue that elected officials have been reluctant to tackle: cost control. Extending insurance coverage to everyone is a moral imperative, but doing so will do little or nothing to hold down the rising price tag of health care, which is driven in large part by the proliferation of "care" that is unnecessary or harmful. In a New York Times editorial earlier this week, David Leonhardt observes that opponents of cost control use "scare stories" to falsely assert that cutting spending always means hurting patients:

Hospitals that practice more intensive medicine, to take one example, get no better results than more conservative hospitals, research shows. And while the insured receive better care and are healthier than the uninsured, the lavishly insured - those households with so-called Cadillac plans - are not better off than households with merely good insurance.

Yet every time Congress comes up with an idea for cuttting spending, the cry goes out: Patients will suffer! You're cutting bone, not fat!

How can this be? How can there be billions of dollars of general waste and no specific waste? There can't, of course. The only way to cut health care costs is to cut health care costs and, in the process, invite politically potent scare stories.

The trouble is, while disease advocacy groups such as the American Cancer Society can trot out endless legions of men whose lives have been "saved" by screening for prostate cancer, for example, you won't hear anything from the much larger numbers of men who have suffered permanent impotence or urinary incontinence due to surgery for prostate cancers that may never have affected their health. (A recent analysis in the Journal of the National Cancer Institute estimated that over 1 million additional men have been diagnosed and treated for prostate cancer in the U.S. since the introduction of PSA screening in 1986, and even under the most optimistic assumptions, only 1 in 20 of these men actually benefited from treatment.)

It's completely understandable that men who undergo treatment for cancer and suffer adverse effects from their treatment want very much to believe that their lives have been saved and that the harms they suffered were worth the cost. Doctors who detect and treat those cancers want to believe this too. In a phenomenon that has been called "a system without negative feedback," all of the incentives in U.S. health care conspire to encourage excessive testing and treatment for individual patients. Only by paying attention to health on the population level can we get a better perspective. Resources are limited, and given this fact, it makes no sense to squander resources on care that doesn't work, or care that hurts more people than it heals. Scare stories about cost control make for good headlines, but the story that scares me is what would happen if health reform passes without it.

Guest Blog: The Rudeness

Rick Kempa lives in Rock Springs, Wyoming, where he directs the Honors Program at Western Wyoming College. "The Rudeness," first published in the Bellevue Literary Review, dates from a time a few years ago when his mother, who is afflicted with Alzheimer's, lived with his family. His work has appeared in the journals ARS MEDICA and The Healing Muse, in the anthology Beyond Forgetting: Poetry and Prose About Alzheimer's Disease (Kent State University, 2009), and in his poetry collection Keeping the Quiet (Bellowing Ark Press, 2008).

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THE RUDENESS

Late in the evening, I hear her shout, "Now, that's a little rude, you know."

I look into her room. She is lying on her back, one hand raised above her head, fingers plucking and pruning the air. Her eyes are tightly closed, mouth working.

"Mom, can I settle you in?" I whisper.

She twists her body towards me, eyes still shut, flings out her hand, grasps a handful of my hair, lets go.

"Mom, what are you doing?"

"Oh, I'm reaching for a word."

"What word, Mom? Can you tell me?"

She grimaces. "Oh, you know ... those words ... I don't know."

Deftly, she probes the air, arm bobbing and weaving like a swan's neck. Sometimes her fingers curl into a loose fist around a space. She holds whatever she has found there, then rotates her wrist outward, unfurls the fist, pushes the platform of her palm skyward, coaxing it to fly, be gone - and resumes her searching.

And I am thinking that I do know, Mom. I too have had the best of them torn from my grasp by a whirlwind. I have chased their flitting shadows across the lawn, walked all afternoon, head hung, without them. I have carried their meanings in my pockets, flashed them at strangers - hey, buddy, have you seen ...? I have sat timidly at tables, seven blanks in the Scrabble rack of my brain, and stared into the faces of nameless friends. At night, I open my mouth - leap of faith! - trusting they will dart home, prodigal hummingbirds. Others arrive instead, grackles and starlings, a sorry tribe of stand-ins and has-beens.

"It doesn't matter," I console her. "These other words will serve us well, or if we arrive at a place where there are none, the silence will not be so bad." But I know now, watching the fist of her mind clenching, unclenching around the space that once held words - the very best, the most perfect words - how wrong I am. This is the rudeness, this is what's unacceptable: that at first they were so gracious, so generous with themselves, and are now so spare.

- Rick Kempa

Healthy skepticism and improving health communication

In yesterday morning's hearing before the House of Representatives Energy and Commerce subcommittee on health, Dr. Ned Calonge and Dr. Diana Petitti, Chair and Vice Chair of the U.S. Preventive Services Task Force, admitted to a "failure in communication" of the Task Force's recently updated recommendations on breast cancer screening when it came to women ages 40 to 49 years. There was, and remains, absolutely nothing wrong with the science of the recommendations, which included advising against clinicians teaching self-breast examinations due to a lack of benefits (a conclusion also reached by the highly respected Cochrane Collaboration more than two years ago) and having mammograms performed every two years rather than every year, as is common practice in the U.S.

In an attempt to correct the widespread perception that the USPSTF had recommended against ALL women under the age of 50 having mammograms for screening purposes, the breast cancer screening page on the USPSTF website now includes a direct quotation from Dr. Petitti: "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether a mammography is right for you based on your family history, general health, and personal values." Although adding this quotation was too late to quell the political firestorm that erupted in the wake of the new recommendation (which was only pushed out of the headlines by the debate over appropriate troop levels in the war in Afghanistan), it is an attempt to translate what had been a statement directed at clinicians for patients and their caregivers.

In an earlier post on this blog, I mentioned how researchers at the Dartmouth Institute of Health Policy and Clinical Practice had developed a book meant to assist patients with understanding health statistics and using data to estimate their personal risk of contracting a disease or experiencing a disease-related event. In an editorial in this week's Journal of the National Cancer Institute, Dr. Woloshin and Dr. Schwartz (writing prior to the release of the USPSTF breast cancer screening recommendations) argue that while headline-seeking journalists are to blame for some of the exaggeration of health risks and benefits, researchers, medical journals, and academic press offices are also responsible for this common phenomenon:

Important elements that journalists (and, really, all readers) need are sometimes missing or hard to find in the published articles. For example, in six high-profile journals, two-thirds of articles reporting ratio measures failed to provide the underlying absolute risks in the abstract. ... Nor are study limitations routinely highlighted in journal abstracts ... and sometimes are missing from articles altogether. ... Only half of the press releases reporting on differences between study groups provided absolute risks; less than one-quarter noted any study limitation. ... Can we really expect journalists to do a better job than the medical journals, researchers, or their university public relations offices?

Studies have shown that women consistently overestimate their personal risk of breast cancer diagnosis, breast cancer death, and the benefits obtained from screening mammography. For the record, a typical 40 year-old woman has 1.4% chance of being diagnosed with breast cancer over the next 10 years, and a 0.33% chance of dying from it (or 1 in 300). Regular screening mammograms reduce the probability of dying of breast cancer in a 40 year-old woman by 0.05%, to 0.28% (or 1 in 357), at the cost of a 1 in 3 chance of experiencing a false alarm due to screening. Whether or not the cost is worth the benefit lies in the eye of the beholder - which is why, despite all of the unnecessary hysteria, the USPSTF got it right.

Residency Procedures

The mantra "see one, do one, teach one" has long been thought to be essential to the training of physicians. But how would you like to be the patient on the receiving end of that training - a medical student or resident doing his or her first (or second, or third) procedure of a particular type? My anxiety about one such situation as a second-year Family Medicine resident at Lancaster General Hospital (PA) in 2002 led to the following tongue-in-cheek poem about the disparity between intellectual knowledge and hands-on ability.

**

PROCEDURES

Have you ever been caught
Too close to a lamp
Unable to immediately turn
To evade the scalding heat?

That's where it starts
Your name in block letters
An article tacked up on a door
The thrill of recognition.

They can't see what you can
But the cost is prose burned
Into areas that ought to contain
Other things - for example,

Being on time for noon conference
The dinner you forgot to pack for that long night on call
The chapters of skin diseases you didn't read
So you have no idea what to do with the ugly mole on this man's back.

But ... perhaps he'll recognize you!
Perhaps he'll say, didn't you write that column in Central Penn Parent Magazine?
Your ignorance scrubbed away in a sterile field
Awaiting decisive excisions with number 10 blades

Then sent off to Pathology, where
Under the piercing gaze of microscopes
They'll dissect your pieces,
Label them separately,
Fix them in formaldehyde
So your slides may be admired for generations.

- Kenny Lin

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.

**

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).

**

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.

**

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

Guest Blog: Advice to the Young Physician

Richard Colgan, MD, is a practicing family physician, Associate Professor and Director of Undergraduate Education in the Department of Family and Community Medicine at the University of Maryland School of Medicine. He is a Past President of the Maryland Academy of Family Physicians and serves as editor-in-chief of the Maryland Family Doctor. This guest post is excerpted from the conclusion to his recently published book, Advice to the Young Physician, which he describes as a book "for those who believe that there is an art to medicine, but are not sure where to turn to learn where to find it, beyond the role modeling which their exemplary teachers display. By looking through the history of medicine, the author identifies some of the recurring themes of the art of medicine, as taught or displayed by some of history's greatest physicians." You can preview the book's cover on my Shelfari bookshelf.

**

THE HEALER'S PRAYER

God, let me begin each clinical encounter by always putting my patient's needs first. Grant me the strength to not be seduced by the allure of worldly pleasures, so as to be the best healer I can be, as I look to be thorough and careful in practicing my art. Guide me as I practice this sacred vocation. May I have the wisdom to learn from the lessons of my teachers, as I contemplate how to best serve each person who seeks my counsel. Help me to use all of my senses as I strive for excellence in caring for my patients, and to understand that if I cannot help someone, then at a minimum I will do no harm.

Strengthen me to have an inner and outer calmness when faced with the inevitable difficulties that lie before me. Show me how to best educate my patients on how to live longer and healthier lives, while being open to learning from those whom I serve. Show me how to be temperate and modest as I look to assist nature by incorporating proper diet, exercise and my patient's own resources in their overall care. Never let me forget that I am caring for someone who is suffering from a disease, and not taking care of a disease.

May I never forget my duty to practice medicine based upon a conviction of pursuing altruistic beneficence, marked by showing compassion for others as I commit myself to a life of service. May I not abandon, but look to serve the poor and advocate for those who suffer because of disparities in our health care system. Remind me to keep matters between physician and patient confidential and that I am accountable for my actions. May I always show respect and care for myself and my family, while being kind in my everyday interactions with others.

I ask you for humility in knowing the limitations of my art. May I always end each encounter with my patient knowing that I have done my best in assisting you by applying the bandages, while taking comfort in the fact that only power greater than I heals.

- Richard Colgan

Doctors' conflicts of interest can harm your health - Part 2 of 3

For the uninitiated (which aptly described me when I attended my first conference, the American Academy of Family Physicians Scientific Assembly in Orlando in October 2004), medical conferences can be truly awe-inspiring things. I'm not talking about the quality of the lectures, procedural workshops, or other officially sanctioned learning activities. I'm talking about the mammoth Exhibition Hall filled with wall-to-wall twelve-foot tall displays marketing the latest blockbuster drugs, medical devices, and electronic gizmos to physicians. Impeccably attired, physically attractive (and in some cases, stunning) salesmen and saleswomen beckoning conference attendees toward their wares - I remember that the Exhibition Hall that year included several high-end massage chairs, an operational 3-dimensional pregnancy ultrasound, and countless smaller "goodies" such as free pharmaceutical company-emblazoned bags, flash drives, cellular phone headsets, prescription pads, and penlights.

The supposed rationale for providing a separate "exhibit hall" is to cordon off commercial activities from genuine medical education. Conference speakers are generally required to disclose affiliations with industry that might represent conflicts of interest (COI); for example, a speaker who works for Pfizer (maker of the popular cholesterol-lowering drug Lipitor) could hardly be expected to give unbiased recommendations regarding threshold levels for cholesterol treatment. Cynics note that because conference organizers rarely make an effort to verify the accuracy of such disclosures, many speakers fail to disclose disqualifying affiliations. Judging from a recent study published in the New England Journal of Medicine, the cynics are right.

In this study, investigators compared the COI disclosure statements of speakers at the 2008 meeting of the American Academy of Orthopaedic Surgeons with publicly reported information from manufacturers of orthopedic devices. They found that more than 20% of speakers failed to disclose payments related directly to the topic of their presentation, and fewer than half of speakers disclosed payments that were judged to be less related to the presentation topic. More than 80 percent of these payments were greater than $10,000; more than 40 percent were for more than $100,000. (By comparison, before I become a federal employee, the largest honorarium I ever received for giving a talk was $800.) Speakers were statistically more likely to disclose payments greater than $10,000 - but it's not as if $9,999 is exactly chump change!

So what do I conclude from this study? That I should never again trust an orthopedic surgeon who tries to teach me something? That I clearly chose the wrong medical specialty, if financial success was my measuring stick? I prefer to look on the bright side: at least these conflicts of interest, and the myriad ways that unscrupulous physicians and commercial interests try to game the disclosure system, are finally seeing the light of day. As President Reagan said about his policy toward arms control during the waning days of the Cold War, "Trust, but verify." That maxim should be medical education's policy, too.

Public option or no public option: that is not the question

I'm interrupting a series of posts on conflicts of interest in medicine in order to say something about health care reform, which is approaching a critical point as Senate and House negotiators try to combine the various bills that have emerged from different committees. One widely reported point of contention is whether or not the final bill should include a so-called "public option," a government-sponsored insurance product that its supporters feel would provide needed competition with private insurers and make the cost of insurance more affordable. Opponents believe that the public option would end up driving private insurers out of business and end up being the only option. While I think that this idea is hardly revolutionary - Medicare, after all, is a "public option" for senior citizens that's been around for 45 years - I also believe that it's a distracting side issue to what our health care system really needs: comprehensive cost control.

Public option or no public option, health care premiums are on a course to consume the entire average income of an American household by 2025 - a mere 16 years from now, when my oldest child will be entering college. While you might think it's okay in an abstract sense to spend a million or more dollars to save one life (especially if it's your life or that of someone you love), even the wealthiest nation on the planet can't afford to pay for every possible intervention that promises a tiny bit of improved health or longer life for somebody. We need to make choices, as a society, about our collective health priorities.

Other measures that have the potential to address skyrocketing costs (but are being underemphasized or completely ignored in the focus on the "public option") include:

1) Flat-fee primary care combined with insurance for catastrophic medical events. Your car insurance doesn't pay for oil changes, your home or rental insurance doesn't pay for furniture, and your health insurance shouldn't pay for basic primary care visits.

2) No-fault compensation programs for all but the most egregious medical errors (e.g., if your surgeon cuts off the wrong leg, or your internist prescribes toxic drugs for conditions you don't have, you would still have the right to sue).

3) Reforming medical education and continuing medical education to provide safeguards against conflicting interests (e.g. pharmaceutical and medical device companies) that lead to inappropriate or potentially unsafe prescribing practices. More on this in future posts, but I think we have a long way to go.

4) Let the insurance "bureaucrats" make informed decisions based on cost-effectiveness of medical interventions. I know that this is an unpopular position. I'm not talking about setting up death panels, or even dialysis panels, which actually existed in the past. And I'm not saying that insurance shouldn't cover every medication or surgery with a high price tag. What I'm advocating is that we take a hard look at what we're getting for the billions we spend on health care, the way you make decisions about how to spend your own limited budget. After all, drug companies still do business with the United Kingdom, even though their National Institute for Health and Clinical Excellence (NICE) applies strict cost-effectiveness criteria to determine whether drugs are worth paying for. If a drug doesn't meet NICE's standard, the company will often lower the cost of the drug so that it does. Not so in the U.S. - which is why we generally pay the highest prices.

Guest Blog: Medicine in Translation

Since I started this blog a few months ago, I've supplied nearly all of the content myself, occasionally quoting others in posts but also adding reflections of my own. However, I always planned to eventually invite guest bloggers with other "common sense" perspectives on health and health care to add to the variety and breadth of content that you will find on this blog, and this is the first of (hopefully) many guest postings.

A practicing internist and Assistant Professor of Medicine at my alma mater (NYU School of Medicine), Danielle Ofri, MD, PhD is the author of three books about her medical experiences and also serves as editor-in-chief of the Bellevue Literary Review. The following piece is excerpted from a blog that was originally posted on the website of Psychology Today.

**

MEDICINE IN TRANSLATION

If asked what a doctor does, most people would probably come up with the standard description of diagnosing and treating disease, usually while wearing an ill-fitting white coat. Before I entered practice, even during my medical training, that probably would have been my answer too. But my years in the trenches of real medicine have altered that definition greatly. I do spend time doing the things I learned in medical school like diagnosing disease and writing prescriptions, but that turns out to be only a part of the job, often a very small part. ...

But when I think about what might be the overriding job description, the one that not only incorporates the above but also extends to the more existential aspects of medicine, I see the doctor as a translator. For most people, medicine is a foreign country, with its own language, customs, and mores. My patients are immigrants to this country, and many feel very disoriented. My job, as their physician, is to translate this alien world for them, to help them acclimatize and hopefully thrive. ...

Being a translator can often be burdensome. It is not enough, as a doctor, to assemble the clinical details, deduce a diagnosis, compose a treatment plan. You also have to be sure the patient understands it all—and that can be an infinitely harder and longer process. But there are also many joys to being a translator. I once had a new patient who suffered from both osteoporosis and osteoarthritis. Her previous doctor had worked out a meticulous treatment plan, including hand-written charts of how and when to take each pill. Yet the patient was entirely confused about her medications.

After a complicated conversation with many false starts, I finally realized that the patient thought that osteoporosis and osteoarthritis were one and the same thing. The pills for each condition were dumped into a communal pill bottle and taken in a random manner. My “diagnosis” was that this patient did not have a full understanding of the language of medicine and that these terms had never been fully translated for her. We spent a long time going over the difference between osteoporosis and osteoarthritis. It wasn’t easy, but by the end of our visit she had a basic comprehension that these were two different diseases and the medicines were treating entirely different things. This patient had many more serious medical conditions to contend with, but she seemed delighted at this small victory, that she finally understood these diseases, that she finally “owned” this aspect of her health.

There was, of course, no place on the insurance form for this sort of effort. The insurance company would never pay my hospital for the painstaking “translation” work that is so critical to good health. But that’s the reality. Luckily there is the patient’s happiness and hopefully improved health that is the real payback.

-Danielle Ofri

Doctors' conflicts of interest can harm your health - Part 1 of 3

As a government employee when I'm not blogging, I think that fears about a "government takeover" of health care have been greatly exaggerated by misunderstanding and persistent rumors (e.g. federal death panels) masquerading as facts. One often-stated fear in the reform debate is that personal medical decisions will be taken out of the hands of doctors. But even those who believe that our health system could use more evidence-based medicine (myself included) generally agree that individual care decisions should be left up to doctors and patients. Have you considered, though, how doctors continue to acquire knowledge to make good decisions after they complete their medical school and residency training? I finished medical school more than 8 years ago, and the aphorism "Half of what you learn in medical school will be out of date by the time you graduate" is more or less correct.

From my experience, most doctors rely on three primary sources of new information: scientific journals (such as the one I edit, American Family Physician), medical conferences, and information from pharmaceutical company representatives (or "drug reps"). You would probably expect information from the latter to be biased, since drug reps are trained to sell drugs, not to do what's best for patients. Organizations such as No Free Lunch have established that physicians who allow drug reps access to their practices to distribute free drug samples, meals, and other promotional products (such as pens, prescription pads, etc.) often end up prescribing expensive or second-line drugs to patients instead of the drugs recommended by national guidelines. Led by the American Medical Student Association, many medical schools have now established strict rules governing interactions between students, faculty, and drug companies.

But pens and drug samples are only the most visible ways that drug companies push their products. Recently, it has become obvious that an entire hidden industry of drug-company funded "ghostwriters" has been publishing articles in medical journals for years. A study by the editors of the Journal of the American Medical Assocation found that from 2-11 percent of articles published in 2008 in six major journals (including the New England Journal of Medicine) were actually written by people who were not named as authors. While the study could not establish that these particular ghostwriters had been directly financed by drug companies, the practice of writing up a scientific study and then recruiting a lead author (usually an academic physician under pressure to "publish or perish") has been well-documented in the case of previous "blockbuster" drugs that were taken by millions of patients for common conditions but later turned out to have dangerous or fatal side effects, including Wyeth's Prempro and Merck's Vioxx.

In an upcoming post, I'll discuss recent efforts by medical journals to save their scientific credibility from the "dirty little secret" of drug company influences.

Post call: resident duty hour regs in perspective

"Post call" is shorthand for being at work the day after having spent the entire previous day and night working. While this sort of situation isn't unique to medicine (for example, attorneys in some specialities pull similar sleep-deprived work shifts early in their careers), it's probably the best known, thanks to medical-themed television shows such as "ER." In the days when medical interns lived at the hospital and were almost exclusively unmarried men, being post call every other day and regularly working more than 100 hours per week was not at all unusual.

Fortunately, by the time I did my family medicine residency (2001-04), matters had improved significantly. Although the Accreditation Council for Graduate Medical Education didn't mandate that programs limit residents to 30-hour shifts and an 80-hour work week until 2003, my program made the change in my second year. We all got more sleep, and I don't feel that quality of care suffered - what experiences I may have missed out on by not stumbling around the wards on a post call afternoon, I made up for by being awake to read more about the patients I was managing. So it strikes me as odd that serious physicians are still debating whether enacting the regulations was the right move - as if the benefits of more sleep to residents can be measured scientifically in any complete and objective way.

In 1997, Vancouver resident Rachel Rose, the author of two books of poetry (most recently, 2005's Notes on Arrival and Departure) published in JAMA what has long been my favorite evocative description of caring for a soul mate who's post call.

**

Postcall

Postcall you come home diminished, wan, your hands
Faltering at the lock. You feel a need to tell me
Each patient’s history before you sleep,
The progress of each malignancy, the way the family
Spoke to you, the suffering that makes death a release.
I understand. But I wait for you, Isabelle,
Not your stories of the progress of the dying.
I lead you to bed like a child, almost crying
With fatigue and despair these anaemic mornings
When you have donated all your strength
And then come home to me, stricken, empty
And grateful for the smallest gesture of tenderness,
My easing your heel from your boot as you undress,
Holding you while you try to reclaim your membership
As one who sleeps. Your limbs twitch
Like a dog’s, hurrying into dreams, your lips
Part with sighs. I soothe you with my weight,
Whisper about the snow piling up outside.
Your eyes close, it’s late afternoon, slow repose
Beckons. But even in dreams your fingers pleat the quilt
As if gathering the flesh of an arm before a shot.
I understand. Accountability never leaves your hands.

– Rachel Rose

Mental health care: a Bellevue success story

Although I trained in family medicine and have practiced in a variety of settings, I've never had the experience of being a small-town family doctor - the kind with an office adjoining his house and who runs into his patients regularly at the grocery store. In fact, the only time I can recall meeting a patient on the street was nearly a decade ago, in Manhattan, of all places, when I was fourth-year medical student who had recently finished a psychiatry rotation at Bellevue Hospital. The experience inspired me to write a poem that I share below. (There is a health care reform angle to this story as well, but I'll save that for another post.) "Sanders" is a pseudonym.

**

CONGRATULATIONS FROM THE COMMUNITY OF TWENTY EAST

I hardly recognized him. How changed
He appeared from that combative, demanding
Patient I knew on those 90-degree days in July!
Then he had been overflowing with suggestions
For his treatment – use this painkiller, not that one –
Living up to the secondhand stories of his terrorizing
Orderlies at Beth Israel. “Can’t anybody see a doctor here?”
Loitering at the nurses’ station, demanding his methadone
On the clock. At war with Sanders over the morality of the unit.
We groaned. Later, dominating therapy groups, he puffed up
With pride at his “progress.” I shied away, leaving him
In the spotlight one last time for others to examine.
Antisocial personality disorder, the attending pronounced.
Sense of entitlement. Which made me wince.
The man just needed a stage. Those final days,
I watched him play spades with the pretty volunteer,
A new man. Praising me to the skies, his Good Doctor.
I saw him on the sidewalk this morning, with headphones
And shiny Giants jacket, inhaling the crisp autumn air.
He shook my hand, wished me the best.

Medication errors and patient safety

When physicians and health care administrators talk about about "improving patient safety," they're usually referring to preventable events that occur in hospitals: blood transfusion mismatches, or infections in intensive care units, to give examples. But the vast majority of health care takes place in communities, in outpatient or ambulatory care settings ("ambulatory" being something of a misnomer, since wheelchair-bound patients can and do seek treatment in offices). In this setting, errors in dosing prescription and over-the-counter medications are an important safety issue.

Taking doses that are too large, or taking correct doses too frequently, can cause serious and even fatal side effects. An advisory committee to the Food and Drug Administration recently voted to lower the maximum daily dose of Tylenol due to evidence that many adults sustain liver damage by inadvertently taking too much. On the other hand, inadequate dosing of medications can result in conditions such as epilepsy, diabetes, and high blood pressure being poorly controlled.

Patients may take medicines improperly because their doctor gives inadequate oral or written instructions. More prescription medications also may make errors more likely. In a 2006 study published in the Annals of Internal Medicine, Dr. Terry Davis and colleagues examined the relationship between literacy levels and a patient's understanding of common prescription drug labels.

In this study, 395 English-speaking adults were recruited from 3 primary care clinics' waiting rooms. They were shown 5 labeled prescription medicine bottles and asked to describe how they would take each medication, including the number of pills to be taken in a day. The interview concluded with a health literacy assessment to determine the patient's literacy level: low (sixth grade and lower), marginal (seventh to eighth grade), or adequate (ninth grade and higher).

Out of 1,975 responses, 374 were incorrect. Most incorrect responses were dosage errors (51.8 percent) and dose frequency errors (28.2 percent). A few patients were unable to find the instructions on the label (5.8 percent) or admitted to being unable to read (3.2 percent). Incorrect responses were strongly associated with low and marginal literacy levels, and the risk of an incorrect response increased with more medications used. Surprisingly, many patients who read the instructions correctly still counted out an incorrect number of pills.

This study reinforced my longstanding (but unfortunately time-consuming) practice of asking all of my patients who take regular medications to bring in their pill bottles at every visit so we can go over how to take each one properly. Quite often, I'd find that another doctor had added or changed a prescription without telling me about it, often leading the patient to take two different medicines for the same condition. Without a single physician coordinating care, medication errors become almost inevitable. So how might health reform address this problem? Stay tuned.

Why "patient centered" health care isn't the norm

If you aren't very familiar with medicine or have had few encounters with the U.S. health system, you may think that the concept of health care being "patient centered" is so incredibly obvious that it shouldn't need to be stated. After all, we wouldn't need health care if people didn't get sick, and the ultimate role of doctors, nurses, hospitals, clinics, and medical technologies is to either prevent patients from getting sick or to help them get well. Yet the term "patient centered" is actually a surprisingly new idea in a complex health care system that has long focused on treating discrete diseases and organ systems (e.g. the heart, the lungs, the kidneys, etc.) rather than whole patients.

When I did my medical training a decade ago, it often seemed to me that medical students were encouraged to depersonalize patients and not listen to their concerns. During my surgical and medical rotations, a patient with stomach pain became "the abdomen in room 6," and the patient with a rare or difficult-to-diagnose illness became a "great case." There was a distinct pecking order within the prestigious academic hospitals where I did my clinical rotations - attending physicians at the top, followed by fellows, residents, nurses, students and other trainees, and finally, at the very bottom, the patients themselves. We took for granted that on the basis of years of studying medicine, we knew what was best for patients, and the few who questioned whether our care was actually making their health better were quickly labeled as "difficult" or "non-compliant."

National patient safety advocate Sorrel King, whose one-year old daughter died in Johns Hopkins Children's Center due to preventable medical errors, writes in her poignant 2009 memoir Josie's Story that being in awe of the technical skills of her daughter's physicians made her reluctant to challenge questionable medical decisions until it was too late. One of the reforms that she and her foundation have encouraged hospitals to adopt is the development of rapid response teams that could be triggered by anyone in the medical hierarchy who had concerns about a patient's condition, including - and especially - patients and family members.

But you don't have to set foot inside a hospital to know that we have a long way to go to get to patient centered care. It's typical in most parts of the U.S. to have to wait months to consult a family doctor about a non-acute problem. When you finally arrive at the office, you often aren't ushered back to an examining room until half an hour or more after your scheduled appointment time, then have to wait some more to actually see the doctor, who may spend five minutes or less with you before he or she is racing off to the next patient. (I'm happy to say that not every practice I've worked at fits this description - for an example of how electronic medical records and "advanced access" scheduling can greatly reduce such inconveniences, see the website of the one of the premier primary care practices in the DC Metro area.)

In future posts, I'll write more about a few important topics that I've only touched on here: improving patient safety, shared decision making, and practice transformation, including the patient centered (there's that term again!) medical home.

Taking the Pulse of primary care medicine

Previous posts may have implied that restoring an adequate supply of U.S. primary care physicians is all about money - that is, less student loan debt and reducing the salary disparity between "front-line" clinicians and subspecialists. If only it were that simple! Alas, even if student loans were forgiven and salaries were doubled, it is unlikely that students would immediately flock to family medicine, pediatrics, and general internal medicine. The reason: time - or more precisely, a lack of it.

Paul Gross, MD, an academic family physician at Montefiore Medical Center in New York and editor of the online magazine Pulse: voices from the heart of medicine, recently wrote a poignant piece about the challenges of family doctoring in the context of 15-minute (or shorter) appointment slots. In "Late Again," Dr. Gross observes:

"The joy of primary care is also its curse. With each patient, I have to keep track of everything--the trivial and life-threatening, the physical and mental, the acute, the chronic and the preventive. And try as I might, I simply don't have enough time. ... My colleagues and I are often still seeing our morning patients at 1:00, when our afternoon session is supposed to begin. Lunch hour? Wouldn't it be nice. And I have it easy. One hears of offices scheduling patients every ten minutes--every ten minutes!--and doctors "seeing" fifty patients a day.

Doctors talk of running on a hamster wheel. Patients complain that their doctors seem distracted, don't take the time to listen, and run late--as I routinely do. Am I a bad doctor--disorganized and inefficient? Or maybe I'm doomed to fall short as I bump up against powerful economic forces--the 'do-more-with-less' pressures that make medical administrators everywhere create schedules like mine, designed to bring in enough money to keep health centers afloat but which end up hustling me and my patients along at an impossible pace. As a nation, we are now trying to fix our foundering healthcare system. Before we set new rules in place, shouldn't we first ask this basic question: how much time is actually required to see a patient?"

As all physicians know, time spent with patients doesn't include time spent documenting visits, reviewing test results, making referrals, filling out administrative paperwork, et cetera. A 2007 study in the Annals of Internal Medicine estimated that doctors in an academic geriatric practice who saw only 14 patients per day (most docs in private practice see 30 to 40) spent nearly 8 hours per week on these non-reimbursed tasks. This reality has led some solo family physicians to adopt a no-frills practice model that relies on few (or no) staff, leading to lower overhead costs and more time to see patients. Unfortunately, more time per patient means fewer patients per day, so such a model applied nationwide would require training even more family physicians, in addition to the ones we already don't have.

Antibiotics, sinusitis, and swine flu

For the past few months, the Giant supermarket chain has offered a free supply of certain antibiotics to customers with a doctor's prescription. As a family physician who is always explaining to patients why antibiotics are ineffective for the common cold, I wish that Giant executives had chosen a more useful class of drug to promote: drugs for high blood pressure or diabetes, for example. While doctors in past years (and, unfortunately, many doctors practicing today) handed out antibiotics like candy, recent scientific studies have shown how limited the medical uses of these drugs really are.

Take sinus infections, for example. They're sometimes caused by bacteria, so antibiotics should help, right? And some studies have in fact suggested that a few patients with laboratory-proven bacterial sinusitis may recover more quickly with antibiotics. But since tests for bacterial sinusitis are not available in primary care practices, it would be useful to identify clinical findings associated with a positive response to antibiotics. In a 2006 study published in the Annals of Family Medicine, Dr. An De Sutter and colleagues at Ghent University in Belgium studied the utility of clinical signs and symptoms of sinusitis and sinus x-rays for predicting duration of illness and the effect of amoxicillin, a commonly prescribed antibiotic.

The study enrolled 300 patients age 12 and older who visited their family physician with signs or symptoms suggestive of a sinus infection. Patients were randomized to take 10 days of either amoxicillin or a sugar pill. No clinical sign, symptom, or x-ray finding had any relationship to duration of illness or response to amoxicillin. The authors concluded that clinical information cannot be used to select patients who would benefit from antibiotic treatment. Consequently, they recommended symptomatic treatment (e.g. over-the-counter pain medication, nasal decongestants), rather than antibiotics, for patients with sinus infections. And so do I.

You may also wonder what you should do if you think you may have the H1N1 (also known as "pandemic" or "swine") flu. The Centers for Disease Control and Prevention has put together a nice web page that answers the most commonly asked questions. When an H1N1 flu vaccine is available next month, it is especially important that pregnant women and young children are at the head of the line, since they are the most likely to become very sick if they get the flu.

Re-priming the primary care pipeline

If you've been reading this blog since its inception, you are now well aware that primary care is essential to any high-performing health system, including those in other countries, but that the "pipeline" for primary care physicians in the U.S. has been drying up, with large student debt burdens and discrepancies in income between generalist and subspecialist physicians playing a large part in driving medical students away from careers on the front lines of medicine. So how can the supply of primary care physicians be increased to adequate levels in the context of health care reform?

A group of family physicians and health policy analysts at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently did an exhaustive study on the factors that affect medical students' selection of careers. In their exceptional March 2009 report, subtitled "What Influences Medical Student & Resident Choices?" Dr. Robert L. Phillips, Jr. and colleagues made several evidence-based recommendations for policymakers that bear repeating (and tweeting) loudly in the White House and halls of Congress:

1. Create more opportunities for students and young physicians to trade debt for service.
2. Reduce or resolve disparities in physician income.
3. Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice, and care of the underserved.
4. Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.
5. Shift substantially more training of medical students and residents to community, rural, and underserved settings.
6. Support primary care departments and residency programs and their roles in teaching and mentoring trainees.
7. Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act. (Title VII is a small, little known federal program that supports primary care residency training, but has been severely shrunk by budget cuts during the past decade.)
8. Study how to make rural areas more likely practice options, especially for women physicians. (The report found that "female physicians are twice as likely as men to choose primary care but helf as likely to practice in rural areas.")
9. New medical schools should be public with preference for rural locations. (One recently established medical school, the Commonwealth Medical College in Scranton, PA, exemplifies how this recommendation will encourage students to pursue primary care careers.)

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In the interest of full disclosure, I'd like you to be aware that the Robert Graham Center is an editorially independent subsidiary of one of my employers, the American Academy of Family Physicians, and I did some freelance editing assignments for the Center from 2005-06. I no longer have any direct professional connections with their staff, but I encourage them to read my blog!