Author Archive

Holiday Buffet

turkey-570935_640In honor of our upcoming Thanksgiving holiday, this blog is a buffet of topics I’ve collected over the past few months.

And as we close this rancorous election season, let’s peacefully reach across the table and settle the debate of what pie to serve: the piecaken will satisfy members of every culinary denomination. Enjoy your meal!

 

Operations Improvement?

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A few months ago I stumbled across a website for a virtual physician assistant called Bright.md. Built around a structured questionnaire, this medical application allows a clinician to remotely collect routine aspects of the patient history. Bright.md figures that it’s time-saving tool can increase physician efficiency up to tenfold — meaning you could cut the typical 20 minute visit to 2 minutes.

And you thought a 15 minute appointment was short.

I can see the value of a product like Bright.md from the physician perspective, but I see little benefit for the consumer. After all, patients complain that their doctors spend too much time with them about as often as my daughters ask to turn off their iPads and go to bed.

There’s an overflow of fat to be skimmed from our health care system, no question. I’m just not sure Bright.md should be part of the cleanup crew.

Eat your Vegetables

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More support for lifestyle modifications that prevent cardiovascular disease appeared in this week’s New England Journal of Medicine. Building on two decades of research showing that healthy habits — defined as not smoking, avoiding obesity, regular physical activity and a diet rich in fruits and vegetables — prevent heart disease, investigators combined four studies totaling over 55,000 patients at highest risk for coronary events.

Their findings were unequivocal: adhering to just three of the four healthy lifestyle habits reduced the risk of heart disease by almost 50%, compared to individuals who maintained an unhealthy lifestyle (no or only one good habit).

To put this in context, cholesterol “statin” medications (think lipitor, crestor, zocor and the like) reduce risk by only 25%. There’s no question that it’s easier to take a pill than follow a healthy lifestyle. But the benefits of the latter extend well beyond reducing the risk of heart disease. Exercise alone, for example, improves your sex life, sleep, mood, and cognition.

Please the Knees

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Finland brought us Angry Birds, an amazingly functional and honest government, and more saunas per capita than you dreamed possible. Add to that list of gifts a growing body of evidence promoting conservative treatment of symptomatic degenerative knee cartilage tears.

Most knee cartilage tears are degenerative — in other words, not associated with a specific injury. For decades, symptomatic tears were treated with arthroscopic meniscectomy (surgical trimming of the torn cartilage), with all the attendant costs ($4 billion annually in U.S. alone) and risks associated with surgery.

In 2013, some U.S. researchers proposed that perhaps we were overtreating these joints. In a landmark study, they documented no difference between conservative (physical therapy) or invasive (arthroscopy plus physical therapy) approaches.

The Finns built on this research with another study in 2013 showing no difference between sham procedure (incisions without surgery) and traditional arthroscopy. Why the sham surgery? So patients did not know whether they were actually operated on or not.

Now they complete the hat trick with a paper involving patients with knee cartilage tears accompanied by locking or catching. Such symptoms have always been considered the gold standard for selection to surgery — the locking/catching is due to the tear, right? But here again, the Finns prove the fallibility of intuition. Patients were no worse off with sham surgery than actual removal of the torn cartilage.

Now it’s Personal

koli-bacteria-123081_640While you are digesting your Thanksgiving feast, remember to acknowledge the bacteria that are helping with the process. Trouble is, that thank-you list just got a lot longer.

Researchers at Aix Marseille Université in France have developed a new way of identifying bacteria via “a culturing approach that uses multiple culture conditions and matrix-assisted laser desorption/ionization–time of flight and 16S rRNA for identification.” Luckily some consumer-minded folks in the group rethought that description and decided “microbial culturomics” was more digestible for the layperson.

Regardless, this method allowed the French scientists to look inside the gut and identify over 1,000 different bacteria. The really impressive accomplishment: 531 of these bacteria have never before been identified in the human intestinal tract. Furthermore, 187 of these bacteria were newly-isolated in humans, and 197 strains are potentially new species. Of course, now they have to figure out what all those bugs are actually doing down there.

As we grow our knowledge of how our bacteria help (and harm) us, we’ll be in a much better position to address the wide range of diseases that we believe are influenced by those microbes, like diabetes, obesity, asthma and allergies.

Now that’s worth giving thanks for. Happy Thanksgiving!

 

 

We’re Not Always Right

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photo credit: NASA

I heard an uplifting story the other day on the radio. It was an interview with the current head of NASA, Charles Bolden, who shared his experience as a youth trying to gain entrance to the Naval Academy. Mr. Bolden dreamed of becoming an astronaut, which for a black man growing up in South Carolina in the 1960s was a lofty goal indeed.

Luckily, as part of the Great Society programs, President Lyndon Johnson had dispatched a retired federal judge around the nation, looking for “nontraditional” entrants to the military academies. Mr. Bolden was saved by a nomination from a congressman from Illinois, after the entire South Carolina delegation declined to consider his application.

But then a strange thing happened. For the next several decades, at every milestone in Bolden’s career — as he progressed through his schooling, pilot training, military service and eventual acceptance into the astronaut program — a letter of congratulations would arrive. The personal note was always hand-signed by Senator Strom Thurmond, the same man who had previously turned down his request for recommendation to the Naval Academy.

The interviewer pressed Bolden for an explanation. Why would Strom Thurmond — a historical supporter of segregation — take such an interest in a black man whose career he had personally tried to derail?

Bolden struggled for an answer. He never inquired as to why the Senator wrote him, nor did they ever have direct contact beyond those occasional, one-sided exchanges. But he thinks the reason lay in some change of the Senator’s moral compass, something that, sadly, he could not admit publicly.

Like the Grinch who had a change of heart, Senator Thurmond might have realized he was wrong. It’s a theory that has been debated for years — and one both Bolden and others have put forward.

In medicine, we’ve taken a long time to embrace the idea that the doctor is not always right. There was a time when questioning a senior physician or specialist consultant was considered insubordination, and risked retribution.

But once a more forgiving philosophy of care takes root, everyone on the healthcare team (including the patient) is empowered to identify — and rectify — potential errors. After all, most complex systems like health care delivery produce complex failures, where multiple people had the opportunity to correct the course but failed.

Our motto: Trust your doctors, but don’t be afraid to question them.

Knowing your fallibility, and being able to appreciate and admit when you have made a mistake, is an attribute that is harder and harder to find in America. Certainly a great deal of this behavior flows from the top leadership of our country. When was the last time you heard an elected official admit an error? When was the last time you heard it from a leader of industry?

I think the administrative folks in Flint, Michigan, have gotten close to an apology, but what got them there in the first place is more alarming than their lack of remorse. Those same state and local officials were so convinced that others had it wrong that they completely dismissed — in fact, aggressively tried to discredit — the clinician and scientists who were sounding alarm bells.

It’s hard to always be right. The amount of energy that is required to constantly defend your position in the face of competing facts or interpretations is enormous. That energy and effort could be much better directed toward understanding the position of your opponent — and in the process, enlightening your own arguments.

Out of an understanding of our own fallibility comes the ability to compromise, and we’ve clearly lost that skill, too.

I’m sorry. I was wrong. Let’s see if we can find some middle ground. We’ll be better parents, spouses, friends and citizens if we have the courage to share these thoughts with those around us. If you left these words off your Valentine’s Day card, it’s never too late to add an epilogue. And you don’t even have to buy another box of chocolates.

Year in Review

calendarIt’s time once again for Baskin Clinic’s annual Medical Year in Review, where we bring you developments in medicine and science that have either escaped the popular press, or deserve deeper scrutiny than most sound-bite shows offer.

You’ll notice a number of topics involve research that reexamines widely-accepted practices or beliefs.

At Baskin Clinic we welcome questions (both from our patients and our colleagues) that challenge the status quo. This constant re-evaluation of what we do, and why we do it, is a big part of our core principles: “Participate, Communicate, Educate.” Read on….

1. No more fasting for cholesterol tests. This longstanding practice was debunked in several excellent studies over the past three years, but only recently gained popularity in the clinic. Even the federal government — not known for its culture of change — has adopted the guideline of not requiring patients to fast. The end result is far more efficient (and just as accurate!). Now patients can combine their lab draw and physical exam at any time of day, without going hours without food.

2. Calcium and vitamin D have no value in the prevention or treatment of osteoporosis. This one was difficult even for us to absorb, especially since it goes against the guidance of several advisory groups.

First, some definitions. Osteoporosis is the medical term for fragile bones caused by structural thinning. Osteoporosis contributes to fractures, which are a major cause of death and disability in older patients.

That supplemental calcium and vitamin D could help reinforce weak bones seems highly plausible, and goes something like this. Bones are made of calcium compounds. Vitamin D helps the body absorb calcium. Taking supplemental amounts of these raw materials should help grow more bone, right?

But sometimes even perfectly reasonable theories turn out to be wrong, as was discovered with the failure of the homocysteine trials at the turn of the millennium. The few studies that have examined supplemental calcium and vitamin D have shown no reduction in fracture risk. And just because recommendations come from an official source, doesn’t always mean they have been well-researched.

Bottom line: supplementing your diet with additional calcium and vitamin D is probably doing little more than enriching the vitamin industry (and raising your risk for kidney stones and heart disease).

3. We disagree with the growing criticism of the annual physical exam. Even The New York Times joined the chorus, publishing an opinion piece by the former White House Special Advisor for Health Policy Ezekiel Emanuel. Dr. Emanuel writes that he’s skipping his annual physical, but will continue to get his evidence-based treatments like annual flu shots and periodic colonoscopy.

That’s easy for him to say, because as a medical professional, Dr. Emanuel knows which treatments are recommended at what ages — something the general public is not always aware of. (Do most lay people know that there now are two recommended vaccines for pneumonia?)

Emanuel argues that the annual exam encourages needless testing on asymptomatic persons — and is therefore a worthless exercise. We’ll concede this point. As a result, you won’t find any routine EKGs or stress tests at a Baskin Clinic annual exam. What you will find (and what Dr. Emanuel overlooks) is the real value of the annual visit: a thorough review of your health goals and health status (including a full review of systems, immunizations, blood pressure and weight).

4. Speaking of blood pressure, what is the ideal goal for patients? The SPRINT trial, a study of over 9,000 middle-aged patients with one or more risk factors for cardiovascular disease, has touched off a lively debate in the medical community about how low is too low in blood pressure control.

True, participants in the experimental arm (BP 120/80 or less) had fewer cardiovascular events — mainly in the categories of heart attack and heart failure — but had higher rates of serious adverse events (faints, low blood pressure, electrolyte abnormalities, or falls). In fact, only 45 people would have to be treated to a lower blood pressure to cause one serious adverse event.

Our take: for the right patient, it’s a reasonable approach, but with caveats. Additionally, there are contradictory data in the ACCORD trial, which studied similar blood pressure goals in diabetics (and found no benefit). Tough to reconcile all this in a tweet, but that didn’t stop thousands from trying. Thanks #SPRINT!

5. In addition to the existing pneumovax, or PPSV-23, there’s a new pneumonia shot recommended for those over age 65. Called the PCV-13, it protects against an additional (you guessed it) 13 strains of pneumonia-causing bacteria. It’s recommended to receive the PCV-13 first, followed eight months later by the PPSV-23. Already had the PPSV-23? Just wait a year before getting the PCV-13. Confused? Scroll down to the graphic at the bottom of this link.

6. Those intestinal bacteria continue to amaze. The gut microbiome is now implicated in the efficacy of certain cancer treatments utilizing the body’s own immune cells (so-called immunotherapy). In two separate papers published just last month in Science magazine, gut bacteria played essential roles in whether or not these treatments were successful. The next logical question: could probiotics someday become a routine therapy for cancer?

7. And we’d be remiss if we did not mention the most pressing health event for the future: global warming. While the topic has received plenty of press since the Paris Climate Change Accord was signed, we’re still amazed that critical issues like groundwater depletion and shrinking snowfalls are receiving only scant coverage. Let’s face it: many organisms can live without oxygen; none can live without water. We’re going to have to get a lot more creative with how we use the fresh water we have left.

8. Lest we leave you feeling depressed, here’s one to rejoice: we may be witnessing a new generation of healthier Americans. The latest tables from the aptly titled Health, United States, 2014 (just published in May, 2015) show that for U.S. children ages 2-5, obesity rates dropped from 12.5% to 10.2% of children measured. Nice work America!

Have a healthy and happy New Year from your friends at Baskin Clinic. Please let us know if we can be doing anything differently for you in 2016.

Year in Review

 

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Well it’s that time of year again… when we review the best medical stories of the past year. This year we broadened our aim to include more than just medical research. Take a look at the curated list of topics that have captured our attention.

1. Grow Your Own

I’m not talking about pot, though that came close to making this year’s list. I’m referring to the amazing work in regenerative medicine that has been quietly humming along for years.

Starting with bioscaffolds to create a “framework” for the final organ, researchers have coaxed pluripotent human stem cells to differentiate into simple organs like the main airway (trachea). More complex organs have been out of reach until now, when researchers managed to grow human intestinal tissue and successfully transplant it into a mouse model.

Regenerative medicine could revolutionize the field of transplant medicine — and bring some relief to the frustrating bottleneck for organs that leaves many patients on waiting lists for years.

2. Personalized Medicine

The concept of tailoring medical treatments to one’s unique genetics just may be the vitamin D of 2014, judging from the voluminous press coverage and expansive editorials that appeared recently. Genomic medicine (often referred to as personalized medicine), even had its own spot in the State of the Union Address.

Unlike all the fanfare for vitamin D, there’s good science behind this idea: that genetic differences are the reason a given treatment doesn’t work for everyone, whether we’re talking about high blood pressure pills or a particular form of cancer chemotherapy.

But while we’d love to see tumors vaporized with the same deadly accuracy as SEAL Team 6, genomic medicine is a lot more complicated than a double tap.

For starters, simply performing the research to elucidate treatments for specific disease subgroups will be expensive and time-consuming. Imagine running not one breast cancer trial for thousands of patients, but dozens of smaller sub-trials on various tumor types, each with its own protocols and drugs. Furthermore, such small numbers make it statistically more difficult to determine complications and adverse side effects of treatments.

3. Mobile Stroke Units

This is perhaps my favorite topic from 2014. Stroke kills nearly 130,000 people annually and is the leading cause of adult disability in the US. And unlike coronary heart disease (think heart attack) — another major killer with nearly 380,000 deaths annually — there are relatively few good treatments for stroke.

The best chance of recovery for someone with an embolic stroke (where an artery in the brain is blocked by clot or cholesterol debris) is to receive tPA, the “clot busting” drug that has become a widespread and successful treatment.

Trouble is, tPA must be initiated within four hours of the stroke. Wait any longer and adverse side effects of tPA (bleeding) present a greater risk than the stroke itself.  Deciding quickly whom to treat is tricky, too; it requires specialized imaging (MRI or CT scan) and evaluation by a neurologist.

To reduce the delay between diagnosis and treatment, some municipalities and hospitals are deploying mobile units with everything needed to assess a possible stroke. While these specialized ambulances are very expensive — upwards of $1M  to build, let alone staff — they hold the promise of making stroke a far less deadly disease. We should have data on how these units are performing within a year or two, so stay tuned.

4. Our Amazing Gut Microbiome

This year we discovered that maybe there was more to being fat than simply eating too much and exercising too little.

True, we all are consuming more calories than we used to, largely in the form of excess sugar calories. You can read more about the dangers of sugar here.

But the idea that people absorb and process calories differently based on the types of bacteria in their gut — and that those bacteria can be permanently altered by exposure to antibiotics early in life — well that’s a mind-blowing revelation.

5. Superbugs

The Feds are finally on the case with the PCAST (President’s Council of Advisors on Science and Technology) report detailing the dangers of antibiotic resistance (like an extra 23,000 deaths annually). That’s as many as die from flu each year.

It’s high enough on the White House agenda to have made it into the State of the Union Address of 2014 (but alas, not 2015). CDC then granted superbugs their own microscopic line item, with a piddling $30M allocation from the $3.9T (yes, that’s trillion) federal budget.

Based on the near-daily reports of new outbreaks, we think $30M was way, way too little. Case in point: the 2016 budget proposal from the White House now includes a $1.2B provision across all government agencies for fighting these frighteningly adaptable microorganisms.

6. The Future is Plastics

Forget those massive great white sharks. The greatest danger in the oceans these days is plastic trash — more than 250,000 tons of the stuff are floating around. From your basic water bottle down to the tiniest micro-shard, plastic is making its way up the food chain, bringing with it a host of endocrine disruptors, toxins and death to sea animals everywhere. Some even argue that plastic should be reclassified as a hazardous waste.

7. Obamacare

It’s a fact: Obamacare has been a tremendous success, judging from enrollment figures (10 million newly-insured Americans and counting). However, as more than one commentator has pointed out, the Affordable Care Act (ACA) does nothing to control costs in our rampantly inefficient, inflationary health care system.

And that just may make this landmark legislation a big liability for years to come. For an excellent summary of the economic shortcomings of ACA, take a look at this video from a recent episode of “60 Minutes.”

8. Food Chain Contamination

Superbugs don’t just hang out in the hospital, waiting to infect unsuspecting patients. Sometimes those bacteria are on our food.

Here’s how it works:

  • Farmers feed antibiotics to their livestock both to prevent disease and to enhance growth. (Hmm… didn’t we talk about antibiotics and weight already?) In fact, 80% of antibiotic use is on the farm, not in the pharmacy.
  • Those farm bacteria then become antibiotic-resistant.
  • During butchering, farm animal carcasses get contaminated with the resistant bacteria, sickening consumers who may improperly prepare or handle the contaminated meat.

This cycle has been in operation for dozens of years, right under the noses of FDA, USDA, and all those acronyms that are supposed to protect us. How bad is it? In 2014 Consumer Reports found that 97% of all chicken parts were contaminated with potentially harmful bacteria. It’s enough to make a meat-eater cry fowl… I mean foul.

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2015 should be an interesting year in the world of medicine and health policy. Stay tuned for updates on these topics!

 

Medical Knowledge in the Internet Age

IMG_0811It’s 11 o’clock at night and I’m just finishing up a note to my daughter Annabel. She’s off on a school field trip to Eastern Oregon — the John Day Fossil Beds National Monument, to be exact.

They’ve been studying water all year long (how it is used, how it shapes the land, and how it influences animal and human life). Given that she is traveling through a remarkable set of climates on her way to John Day, I drew up a matching game for her — and amazed myself when I discovered the answers.

See if you can match the annual rainfall numbers for the following cities: Portland, Cascade Locks, Hood River, and The Dalles.

a) 42 inches

b) 32 inches

c) 14 inches

d) 78 inches

Skip to the end of this post for the answer. Hint: it all has to do with the prevailing winds.

The excitement and satisfaction of answering one’s own questions in real time is one of the great pleasures of learning in the digital age. Think of the steps required to obtain these figures just 20 years ago. Finding those four little nuggets of information would have entailed a trip to the library, a consultation with the librarian, and a lot of page-turning through thick reference volumes.

Now, from the comfort of my own home and armchair, I can find these same answers in mere minutes. It’s as if I had the star of Jeopardy — not just any Jeopardy star but that guy who lasted like a year on the show —  sitting by my side.

Preparing this tutorial for my daughter also explains why I love being a doctor in the 21st century.

These days I don’t have to rely solely on the (sometimes biased) recommendations of sub-specialists. On my own, I can research a topic outside my practice area and then discuss intelligently with a sub-specialist — instead of simply accepting their view on the topic. It’s quite empowering, and leads to some wonderfully spirited discussions.

And reference books? Who needs them anymore? Mine work best as ballast to keep my mostly empty bookshelf from toppling over. Now I rely on constantly updated services like UpToDate, a peer-reviewed medical encyclopedia directed toward the clinician, not the professor (translation: it’s practical information on diseases and their treatment).

And without fail, all of us in the medical field experience the thrill of new research results that challenge prior assumptions. Just last week I read a new study showing influenza is often asymptomatic, meaning a significant number of flu cases never exhibit symptoms. Wow — does this mean there are human viral carriers out there spreading flu? Stay tuned.

Ready for that matchup? The answers are a) Portland, b) Hood River, c) The Dalles, and d) Cascade Locks.

That’s right, Cascade Locks, 43 miles EAST of Portland, receives nearly twice as much rain. But go less than 20 miles further east to Hood River, and annual rainfall shrinks by more than half, to 32 inches. And you can’t blame it on Mt. Hood — it’s 50 miles to the south.

Two reasons: prevailing winds in the state are west to east, and the Gorge acts as a giant funnel, causing those westerlies to converge right over Cascade Locks. The resulting uplift causes cooling and (lots) of condensation — similar to what happens when wet Pacific winds push up the western flanks of Mt Hood. (Why do you think they chose Bull Run as the location for our water source? Lots of rainfall.)

As those Gorge winds push on east to Hood River, the drier air has less moisture to release, and there’s also less convergence effect due to geography.

Voila, microclimates in action. And you thought this was just another medical blog.

Year in Review

IMG_2235Reflecting on the medical literature of 2013, I’m reminded of what my tennis coach always preached before a match. “If they knew who was going to win the tournament, they’d just give the trophy to the first seed.”

Medical knowledge is, like a win-loss record, built incrementally. Sometimes the results of one study contradict another, yielding whipsawing recommendations that leave everyone (including physicians) a bit confused. And year after year, the research almost always produces a surprise or two, knocking a long-held conclusion off its perch. Here are our picks for the most important primary care studies and revelations of 2013.

1. Frequency of bone mineral density (BMD) testing can be extended. The BMD is an important predictor of fracture risk. But once it’s assessed (by a DEXA scan) at baseline, what is the ideal interval for retesting? This study showed that an average retesting interval of four years added little to the fracture risk calculation. In other words, the extra measurement did not help to determine who is at risk for developing a fracture or osteoporosis. These results add to an earlier 2012 paper showing that the BMD testing interval could be stretched to 15 years for women with normal baseline BMD at age 65.

2. Regular pelvic exams may be unnecessary. Earlier research showed that the bimanual pelvic exam produces a lot of unimportant findings that nevertheless then need followup. There are easier ways to determine vaginal health (pH paper) and presence of STDs (urine tests or vaginal swabs). Now a growing number of experts are recommending we discard the practice of regular pelvic exams altogether.

3. Routine cholesterol tests for those on statin medication are unnecessary. New guidelines instruct that once the decision has been made to treat, documenting the amount of cholesterol lowering achieved is immaterial. This is because statins lower heart attack risk by altering other biological processes (such as inflammation) in addition to simply lowering LDL cholesterol. Case in point: cholesterol medications lower cardiovascular risk even in persons with normal LDL levels.

4. Our government is still not doing enough to prevent contamination of the food supply with harmful bacteria. This study showed most chicken, including samples from organic brands, was tainted with everything from E. coli to salmonella. Even worse, widespread antibiotic use in farming promotes the development of bacteria that are resistant to treatment. Foodborne infections cause up to 23,000 deaths annually — comparable to the annual number of deaths caused by leukemia. The FDA acted just last month to tighten antibiotic use in food production, but many say the rules are not strong enough.

5. Prostate cancer screening continues to frustrate both patients and physicians alike. Should we or should we not check prostate specific antigen (PSA), the blood test by which most prostate cancer is diagnosed? The data are so conflicted, “You can find support for just about any position you take on screening,” one of my favorite urologists opined recently. This new study suggests we might get by with far fewer PSA tests during a man’s lifetime than previously thought.

6. Overdiagnosis and overtreatment, and the recognition of the harms they cause, continue to be a hot topic in the popular press. Take a look at what the medical profession is doing to try and change provider (and patient) understanding of this important concept.

7. Daily multivitamin use is worthless. This strongly worded editorial drew on several recent studies showing lack of benefit for daily multivitamin use. While some specific subgroups do need supplementation (folic acid for pregnant women, for example) the majority of us don’t need a supplement.

8. Arthroscopy (knee scope) may be overutilized. More than a third of randomly selected people over the age of 50 have evidence of knee cartilage injury. Additionally, surgical trimming of torn knee cartilage is one of the most common orthopedic procedures. In this study, individuals with persistent knee symptoms, and evidence of cartilage damage, underwent surgical meniscal trimming or sham (“pretend”) surgery. There was no difference in patient reported symptoms at one year post-procedure, suggesting that surgery offered no additional benefit.

Happy New Year, and best wishes from Baskin Clinic for your good health.

Consumer Driven Health Care Goes Astray

consumer driven health careWhile consumer-driven health care aims to increase the transparency, accountability, and quality of U.S. medicine, occasionally this concept goes off the rails. Here are two business models that miss the mark.

The first, ZocDoc, professes to help its clients “by revealing the ‘hidden supply’ of appointments… [and] get access to care in just 24 – 72 hours.” It’s an online service where you type in your desired specialty, zip code, insurance plan and presto! out comes a list of available providers. It’s as easy as making a dinner reservation on Open Table. In fact, founder Cyrus Massoumi often makes the same comparison when discussing his new company.

ZocDoc’s business model assumes that correctly diagnosing your chest pain as cardiac, pulmonary, or gastric origin is as simple as determining whether you want Vietnamese or Thai food tonight. And while the consequences of choosing poorly on Open Table is a lousy meal, the result of selecting the wrong specialty can be disastrous: you might spend days, or even weeks, traveling down the wrong diagnostic path — or worse. In medicine, we refer to this as “delay of diagnosis,” and it’s a common cause of injury to patients (and malpractice lawsuits).

Furthermore, inefficient workups can be really costly. In this era of shrinking health plan benefits, those costs are yours to bear.

And once you’ve self-selected your specialty, how do you choose the provider? ZocDoc provides user reviews. But online reviews have their own pitfalls, as this recent New York Times article describes.

On the company’s website, Mr. Massoumi writes that “after I ruptured my eardrum on a flight, I couldn’t find a doctor for four days. I knew there had to be an easier way for patients to find doctors.”

What’s missing from Mr. Massoumi’s complaint is that this delay was almost certainly because he didn’t have a primary care doctor. If he had been connected to a primary care physician, Mr. Massoumi could have called and described his symptoms, and likely received a prompt appointment.

Additionally, while the success of ZocDoc indicates there are plenty of providers with time on their hands (as evidenced by the fact that they will pay $300/mo to advertise their open appointments on the ZocDoc platform), our experience is that most well-respected, popular physicians have long waiting lists.

Sadly, many consumers are choosing to follow Mr. Massoumi’s siren call and become their own clinicians — instead of demanding better primary care from their health insurers.

The second alarming trend in consumer-driven health care is the rapidly morphing convenience clinic. Originally designed to provide limited services as a complement to the more intensive (and expensive) hospital emergency department, convenience clinics do a great job at offloading non-critical injuries and illnesses.

But when there’s money and market share at stake, no one is content to stick to their core competency. Remember when toaster ovens were small, convenient little miniature ovens? Now they’re the size of microwaves and can cook a small turkey. Convenience clinics are headed in the same direction, trying to provide continuity care, urgent care, onsite corporate medical care, and heaven knows what else.

Trouble is, convenience clinics are not continuity clinics. They’re primarily run by mid-level practitioners, have a rotating staff, and are ill-equipped to manage the complexities of chronic health problems.

Good chronic care requires time, something most urgent care clinics are not designed to provide. Take a look at the chronic care scheduling for ZoomCare, one of several urgent care chains in town: they have only 15 minute appointment slots. That approach works great for diagnosing sore throats, but is more challenging to pull off when you have a hypertensive, obese, poorly controlled diabetic patient sitting in front of you.

And while most urgent care issues can be addressed in one visit, chronic care requires multiple visits with the same provider — something urgent care clinics are not accustomed to providing.

Consumer-driven health care has great potential. In fact, the Baskin Clinic model of direct primary care is part of this initiative. But like many social movements, consumer-driven health care has plenty of subversive elements eager to redirect that energy. And those alternatives don’t always benefit the public.

Our Bacterial Neighbors

While NASA is busy sending rovers to Mars and hurling satellites into the furthest reaches of space, another branch of government is looking inward. Welcome to the Human Microbiome Project, an innovative program of the National Institutes of Health that is seeking to better understand our closest neighbors.

There are over 10,000 different microbial species living on and in us — hitchhikers that in almost all cases are happy to chip in a few bucks for gas, check the tires, or otherwise help make our trip through life more productive and stable. What’s more, these generous microscopic characters are often essential for our wellbeing, producing vitamins, protecting us from infection by more toxic bacterial competitors, and perhaps influencing our body weight.

Our microbial sycophants are so numerous that they outnumber our own cells by a factor of 10 to one. That’s 100 trillion bacterial cells we’ve got to shoulder. Luckily they don’t weigh much or we’d be overloaded and overcrowded.

The most interesting microbiome study this year concerns a human product no one likes to talk about — poop.  In February, The New England Journal published amazing results of fecal transplantation for patients suffering from chronic C. difficile, a debilitating gut infection often associated with antibiotic use. A single treatment of donor feces cured an impressive 94% of patients.

While antibiotics have a clear association with opportunistic infections like C. diff, the relationship between antibiotic use and other gut illnesses is less clear. But a study in the American Journal of Epidemiology (which received far less press than it should have) documented the strong association between antibiotic use prior to age six and the subsequent development of inflammatory bowel disease (IBD), specifically Crohn’s disease.

The theory is that the alterations of gut flora that occur with antibiotic use may set patients up to develop IBD. Adding support to this theory are multiple small studies examining fecal transplantation in Crohn’s and ulcerative colitis patients, most of which showed favorable results.

Should we all be taking a probiotic supplement? After all, probiotics are loaded with the “good” bacteria that all those C. difficile patients are lacking — so the tempting answer is “yes.” But while the underlying data are suggestive, we don’t have much evidence that probiotics help outside of specific situations (giving a probiotic while on antibiotics, for example). And there is evidence that probiotics can produce complications of their own, though typically these case reports involve patients who have underlying immune compromise or chronic disease.

Future research will focus on conditions of disordered digestion and absorption that might benefit from repopulation or alteration of populations of gut bacteria. Unfortunately, the federal government has now decided to regulate donor feces as a “biologic product” — even though the procedure has been in practice for decades.

So be kind to your bacteria. Don’t use antibiotics unless absolutely necessary. Avoid antibacterial soaps (plain soap and water is just fine), antibacterial-impregnated household items, and toys. And for heaven’s sake don’t worry about a little tracked-in dirt. It might just be good for you.

Guns in America

 

A chronically disturbed or angry young man in close contact with weapons of mass destruction has always been a dangerous combination. It’s a recipe that this country has cooked time and time again, with disastrous human consequences.

And if it seems as though our country has been preparing the same dish of sorrow for the past few years, we have. The New York Times published a graphic listing the 11 worst mass shootings in the US since 1949, noting, “Many of the deadliest shootings have happened in the past six years.”

But graphics can be misleading. In reality, the overall level of violence in the US has declined dramatically since 1990. For example, the homicide rate in cities with a population of 1 million or more dropped from 35.5 homicides per 100,000 US residents in 1991 to an all-time low of 11.9 homicides per 100,000 US residents in 2008. There are many explanations for the trend; most focus on changing demographics (fewer crime-prone young men in our population as the birth rate has slowed), drug use (declining popularity of crack cocaine) and availability of guns.

Even though the homicide rate has been cut over the past 20 years to levels not seen since the 1960s, it’s no reason to celebrate. The US has a far higher overall homicide rate, and far more gun homicides, than any European nation.

In 2006, the US had 3.9 gun homicides per 100,000 population. By comparison, Western Europe had rates per 100,000 of 0.1 (Denmark, United Kingdom) to 0.7 (Italy) — an almost 40-fold difference with the US.

Other astonishing statistics, all taken from the highly informative Homicide Trends in the United States, 1980-2008 (US Department of Justice):

  • approximately two-thirds of all homicides involved guns, and this rate has been relatively stable since 1960
  • much of the increase in homicides during the 1990s was due to handgun violence
  • when circumstances of a gun homicide are known, the most frequent inciting event is a simple argument (as opposed to a felony).

Together, these statistics suggest strongly that rates of gun ownership are associated with homicide rates. In fact, one of the stronger risk factors for gun violence is the presence of a gun in the household. But there are many other factors that contribute to a high homicide rate.

The United Nations Office on Drugs and Crime published an illuminating report on homicide throughout the world, aptly titled the 2011 Global Study on Homicide.

While the report runs some 100+ pages long, the introduction contains a quick summary of the usual suspects. The authors cite organized crime and drug trafficking (and the guns they incorporate), high levels of income inequality and weak rule of law as prime drivers for a high homicide rate. These factors explain why much of Central and South America has varying levels of gun ownership but generally high levels of gun homicide — far higher than in the US. For example, despite a very stringent national gun policy, Brazil’s rate of gun homicide in 2010 was 18 per 100,000 population, or about six times the rate in the US.

The Newtown massacre has drawn our attention, once more, to what a violent country we live in. Now it is time for us to act. As Elie Wiesel, winner of the Nobel Peace Prize in 1986, implored in his acceptance speech: “There may be times when we are powerless to prevent injustice, but there must never be a time when we fail to protest.”

Is High Blood Pressure Overtreated?

US medicine has long been accused of over-utilizing therapies with dubious clinical benefit — like imaging tests for back pain. Now add drug treatment of hypertension (high blood pressure) to that list, according to the conclusions of a highly respected evidence-based research group known as The Cochrane Collaboration.

The Cochrane report has surprised many of us in primary care – especially since we’re the ones that usually diagnose and treat hypertension. My informal poll of several colleagues elicited responses of amazement (and some disbelief).

After all, under the auspices of the American Heart Association and the Joint National Committee on Hypertension – the two leading advisory bodies on high blood pressure — we’ve been trained that even stage 1 hypertension (140-159 systolic over 90-99 diastolic) deserves immediate attention. Patients in this category almost always receive medication.

Perhaps this is because these same advisory groups, along with our own federal government, for years have been making a big deal about pre-hypertension. If we’re expected to pay close attention to readings in the range of 120-139 systolic over 80-89 diastolic, then surely something higher warrants treatment, right?

Indeed, the new online high blood pressure calculator developed by the AHA concludes that patients with Stage 1 hypertension should “talk to your health professional… your doctor will probably prescribe medication to help lower your blood pressure.” Cynical visitors to the site will note that the only two corporate sponsors — Omron, which makes home blood pressure monitors, and Schering Plough, whose parent company Merck makes several antihypertensive medications — have much to gain from aggressive treatment of hypertension.

High blood pressure is not the only major lifestyle disease that has suffered from over diagnosis — the medical equivalent of “mission creep.” Drug companies have pushed hard to broaden the scope of many disease treatments to include individuals with mild symptoms, or none at all. This ensures the largest possible pool of patients to drive sales and, in turn, profits.

Take hypercholesterolemia and its main medication treatment, the statins. The first studies sponsored by pharmaceutical companies solicited sick patients – those who had already suffered heart attacks and had significant elevations of cholesterol. Result? Proven evidence that statin administration cuts the risk of subsequent heart attack and sudden death.

Over the next 20 years, drug companies spent billions of dollars on marketing and subsequent research to expand their clinical beachhead. Statin treatment has now been extended to individuals with relatively normal cholesterol and minimal risk factors — with supporting research sponsored by drug manufacturers.

But rooting out this low-level disease risk produces diminishing returns. Once again, The Cochrane Collaboration has taken aim at this practice, arguing that the benefit is so small as to make irrelevant the drug treatment of high cholesterol in individuals without underlying heart disease.

Similar arguments have been made with treatment of pre-diabetes – the glycemic no-man’s land between normal (fasting blood sugar of less than 100) and diabetes (fasting blood sugar above 125). While individuals with pre-diabetes have an increased risk of developing full-blown diabetes, treating them as diabetics (with medications to lower blood sugar) appears to offer no benefit and only creates needless risk of medication side effects.

And while modest treatment of diabetes is proven to reduce complications of this devastating disease, recent studies have revealed aggressive diabetic management to be risky, resulting in overall higher death rates even in those most likely to benefit (individuals with poorly controlled diabetes and risk factors for heart attack or stroke). The study evaluating this strategy (known as the ACCORD trial) was stopped early due to these severe complications.

That’s not to say that primary prevention is a lost cause. Modest daily exercise cuts risk of cardiovascular disease (heart attack or sudden death) by nearly half, and minimal weight loss and exercise in pre-diabetics can cut the risk of developing full-blown diabetes by about half also. But sadly, this non-pharmacologic, non-surgical approach is not the course that primary prevention typically follows. Usually we resort to a pill or procedure, either because it is more convenient for the patient, or the provider (or both).

There’s been a great deal of debate in this country over various strategies for health insurance coverage, but precious little regarding the efficacy and cost of various treatments. This is the next step in the evolution of our very flawed health care delivery system, and if readers thought that passage of the Affordable Care Act was a wrenching process, standardizing and validating the care that is provided under the Act will be magnitudes more disruptive.

As for me, while I’ve always encouraged exercise, diet, and weight loss as good adjuncts to drug treatment for hypertension, I’ll now have to place them front and center as first-line therapy, instead of medications. Wish me luck.

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