Saturday, March 28, 2009
Friday, March 27, 2009
On the Daily Beast's website, Dr. Abraham Verghese writes about the problem of a shortage of primary care physicians.
President Obama’s proposal to solve the nation’s health-care woes includes a plan to commit billions of dollars to “digitizing” medical records. Incredibly, there is much more money flagged for that goal than for easing the critical shortage of primary-care physicians. That suggests to me thatthere’s a voice not being heard in this debate. It’s not the voice of Medicare or insurance companies or organized medicine--it’s the patient’s voice.If health-care reform puts billions of dollars into programs that add more computer screens and create more iPatients, but does nothing for the true care of the patient, things will only get worse.
The patient’s voice, alas, is difficult to hear even in our hospitals, because the patient in the bed is overshadowed by machines and activity; the anxious soul under the covers has become a mere icon for the “real” patient in the computer. Indeed, the “iPatient” (my term for this virtual patient entity) has never been better cared for: buffed up and polished, with pop-up flags telling physicians when to feed and bleed and send postcards to bring them back to the office. And if health-care reform puts billions of dollars into programs that add more computer screens and create more iPatients, but does nothing for the true care of the patient, things will only get worse.
Real patients will tell you they want real, live physicians. Most diagnoses can be found in the patient’s history, in the story the patient has to tell. But you can’t hear it if you aren’t listening, and you can’t listen if you’re staring at the computer screen. You have to be with the patient to hear their story; the telling is important. Real patients want someone whose examining skills, when combined with common sense and sound judgment, can spare us the costly, blind, shotgun, ‘tick-all-the-boxes” kind of testing and imaging that has come to be the American brand of medicine. We want a doctor who orders tests judiciously, who calls in specialists sparingly, and who rides herd on them and weighs and translates what they say. What we want, in other words, is a primary-care physician.
A bank collapse, an auto-industry collapse, hurts the pocketbook and is easily measured. But the dwindling numbers of primary-care physicians is just as devastating and will cost us even more in the health of our nation. That‘s the crisis we are facing. Instead of pouring money into “digitizing the medical records,” we need to rescue primary care. . . .
The Center for American Progress details the cost of the uninsured in a new report. The report details the $1100 cost-shifting from the uninsured to the insured under our current health care system. The report by Ben Furnas and Peter Harbage provides,
affordable, and effective health insurance, and we’re all paying the price.
The Center for American Progress has updated a 2005 analysis by Kenneth Thorpe
for Families USA and found that, on average, 8 percent of families’ 2009 health care
premiums—approximately $1,100 a year—is due to our broken system that fails to
cover the uninsured.
The best way to address this burden on health insurance is to create a more efficient system
that offers continuous, quality coverage for all. We can’t afford our broken system any more. . .
Approximately 87 million people—one in three Americans—went without health insurance
for some period during 2007 and 2008,1 while rising unemployment and job losses
caused an estimated 14,000 people to lose their health insurance every day in December
2008 and January 2009 alone.2
Some mistakenly believe that the plight of the uninsured, and America’s failure to provide
continuous quality health insurance for everyone, only affects those who are unable to find
health insurance. But this is wrong.
The uninsured pay more for care—and get less—than those with insurance. But when the
uninsured cannot pay, health care providers shift those costs to those who can pay—those
who have insurance coverage. 3 This leads to higher premiums for those who buy their
insurance on the individual market, as well as workers who get insurance for themselves
and their families through their job.
Thursday, March 26, 2009
THe Daily Beast website has a brief story about the possibility of a suicide gene. Casey Schwartz writes,
The news on Monday that Sylvia Plath’s son, Nicholas Hughes, had killed himself, reopened a macabre chapter of literary history. Obituaries revealed spare and suggestive details. Hughes, the son of the poet Ted Hughes, lived in Alaska and worked as a biologist, studying the travel patterns of fish. Recently, however, he had left his job to focus on pottery making. Hughes was still an infant when his mother committed suicide in 1963 by putting her head in a gas oven; he was seven when his father’s second wife, Assia Wevill, killed herself (and her four-year-old daughter) by exactly the same means. And 40 years later, on March 16, 2009, Hughes took his own life, hanging himself in his Alaska home . . . .
There is more than just anecdotal evidence behind the claim that the suicide of one family member increases the chance that other family members will attempt suicide, or successfully carry it out. A study in the Archives of General Psychiatry published in 2002 found that children whose parents had attempted suicide were six times as likely to try taking their own lives. Twin and adoption studies have revealed that a disposition toward suicidal behavior is partially heritable. Researchers have scrutinized the phenomenon, struggling to untangle the psychological factors from the genetic. . . .
“We grow up and we learn how to be by either imitating or negating our parents,” says Dr. T. Byram Karasu, university chairman and professor at the Albert Einstein College of Medicine at Yeshiva University. “So if you identify with one parent who happened to be suicidal, you may end up having suicidal ideation even though you’re not depressed. It becomes like a norm.” . . .
Within this thicket of factors, researchers are searching for genetic clues. The idea that a handful of genes could ever be confidently singled out in explaining the act of suicide—in all of its complexities and variations—is deeply improbable. But a group of researchers led by Columbia University psychiatrist John Mann published a study earlier this year that directly grapples with the issue. The researchers attempted to break down suicidal behavior into individual characteristics that can be more closely identified with specific genes. Their approach focused on what is known in the genetics world as “endophenotypes"—heritable traits that are associated with both the gene and the illness, but not synonymous with either—and which include impulsivity, major depressive disorder, and natural stress hormone response.
There is no one reason for why someone would choose to end their own life, but the suicide of any public figure seems to ignite a reflexive need to speculate. In the case of Nicholas Hughes, it might seem self-evident to point to the tragic luster of his family. But for now, the explanation eludes us.
Wednesday, March 25, 2009
Yesterday's Talk of the Nation has a panel discussion concerning reviews of doctor performance appearing on websites and some doctors who are asking patients to sign waivers that they will not post items on websites without approval. The brief write-up is below and the podcast is here.
The Washington Post has a good story on the federal district court decision on the morning-after pill and the FDA's decision in 2006 to refuse to permit young women below the age of 18 access to it. Rob Stein writes,
A federal judge ordered the Food and Drug Administration yesterday to reconsider its 2006 decision to deny girls younger than 18 access to the morning-after pill Plan B without a prescription. U.S. District Judge Edward R. Korman in New York instructed the agency to make Plan B available to 17-year-olds within 30 days and to review whether to make the emergency contraceptive available to all ages without a doctor's order.
In his 52-page decision, Korman repeatedly criticized the FDA's handling of the issue, agreeing with allegations in a lawsuit that the decision was "arbitrary and capricious" and influenced by "political and ideological" considerations imposed by the Bush administration."These political considerations, delays and implausible justifications for decision-making are not the only evidence of a lack of good faith and reasoned agency decision-making," he wrote. "Indeed, the record is clear that the FDA's course of conduct regarding Plan B departed in significant ways from the agency's normal procedures regarding similar applications to switch a drug from prescription to non-prescription use." FDA lawyers are reviewing the decision, said Rita Chappelle, an agency spokeswoman, who declined to comment further.
Critics of the FDA's decision hailed the ruling. "We're very excited," said Suzanne Novak, a senior staff lawyer for the Center for Reproductive Rights, which filed the lawsuit. "The message is clear: The FDA has to put science first and leave politics at the door."
Opponents of Plan B condemned the judge's order. "This ruling puts politics above women's health, and intrudes into parents' ability to protect their minor daughters," said Wendy Wright of the group Concerned Women for America. She also questioned the drug's effectiveness. . . .
Susan F. Wood of George Washington University, who resigned from the FDA because of the agency's delays, noted that several officials involved in the decision are either still at the agency or in other key government positions, including Janet Woodcock, who heads the FDA's drug approval office, and Steven Galson, now acting surgeon general and assistant secretary of health. But Wood and others said they are confident that the new leadership at the agency will make Plan B widely available after reviewing the case.
"I think FDA is now in a position where it can make a fair decision because of the change in leadership and the commitment by everyone involved to make science-based decisions," Wood said. "This is a chance for the agency to demonstrate it is back on track."
President Obama recently announced plans to name former New York City health commissioner Margaret A. Hamburg as FDA commissioner and Baltimore Health Commissioner Joshua M. Sharfstein as her deputy. He also issued an order he said was designed to insulate scientific decisions throughout the government from political influence. . . .
Tuesday, March 24, 2009
The New York Times has an interesting article on some recent difficulties Swedish medical schools have had with criminals applying and being accepted at their schools. Dr. Lawrence Altman writes,
In contrast with the United States, Swedish laws and customs are sympathetic to released offenders, saying that once they have served their time they should be treated like ordinary citizens. But the cases raise questions about protecting the rights of patients and fellow medical students and health care workers.
Entry to Swedish medical schools is highly competitive. At Uppsala, for example, a spokeswoman said there were 2,603 applicants for the spring semester and just 100 admissions. They include Mr. Svensson, who is taking up a taxpayer-financed slot that could have gone to another student.
Indeed, the Uppsala County Council, which runs all government health facilities in the area, says it will not allow Mr. Svensson to do any clinical work, which is a critical and mandatory part of medical school training. That raises questions about how he will complete a degree even if he does attend classes.
Mr. Svensson, who has not responded to numerous attempts to reach him over the last year, was convicted in the 1999 hate murder of a trade union worker and was paroled after serving 6 ½ years of an 11-year sentence — a typical penalty for murder in Sweden. He entered Karolinska in fall 2007 while still on probation; he had earned credits for medical school while in prison. . . .
The disclosures about his past proved deeply embarrassing to the institute. Among other things, two senior faculty members on the admissions committee that interviewed him failed to ask for an explanation of the six-and-a-half-year gap in his résumé, the period he was in prison.
Swedish universities are legally prohibited from conducting background checks on applicants. To complicate matters, Mr. Svensson legally changed his surname from Hellekant after his conviction.
The Swedish medical licensing agency said that it would not allow Mr. Svensson to practice even if he earned his medical degree. But because the agency’s jurisdiction excludes universities, questions arose about whether and how medical school officials should inform patients examined by Mr. Svensson about his criminal past, and what the patients’ responses would be. . . .
Last year, Karolinska officials, acting in part on a committee’s recommendation, exhorted the Swedish parliament to enact legislation to allow medical schools a freer hand in admitting and dismissing students in cases where they would have patient contact. But little has happened. . . .
Today's Diane Rehm Show discusses the Obama Administration health reform effort and whether this is the time to initiate such major changes. Here is the lineup:
10:00 The Politics of Health Care Reform
Some argue health care is central to any meaningful economic recovery in this country. How the current economic downturn and massive budget deficit projections are affecting political resolve for healthcare reform.
Laura Meckler, is a reporter for "The Wall Street Journal." She covers the White House with a focus on domestic policy and health care.
Joseph Antos, is Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute.
Ron Pollack, is Executive Director of Families USA, a national non-profit organization for health care consumers.
Monday, March 23, 2009
AMNews.com reports on the changing relationship between doctors and representatives from pharmaceutical companies. Kevin O'Reilly writes,
Pharmaceutical companies -- battered by a sluggish drug pipeline, the looming loss of blockbuster patented drugs, an economy in recession and scrutiny of their relationships with physicians -- are re-examining the value of sending drug reps into doctors' offices. Detailers are struggling to grab a shrinking slice of physicians' valuable time and attention while adjusting to new drug industry rules banning freebies such as pens and notepads. . . .
About one in four physicians works in a practice that refuses to see drug reps. Of doctors who do see reps, about 40% will meet with detailers only with scheduled appointments. The by-appointment-only figure jumped 23% during the last six months of 2008, according to a survey of more than 227,000 medical practices representing 640,000 physicians that was released in February.
The survey, conducted by the doctor-profiling firm SK&A Information Services Inc., did not seek to determine why some physicians are giving drug reps the cold shoulder. But physicians and pharmaceutical industry consultants say doctors have felt besieged by the number of reps visiting their offices and taking up precious time in an era of declining payment. . . .
Here is the chart attached to the article showing the different ways that physicians deal with various drug representatives.
|1 to 2 doctors||14.3%||32.5%|
|3 to 5||16.7%||36.1%|
|6 to 10||23.1%||45.0%|
|More than 10||44.0%||45.5%|
Source: "Physician Access: U.S. Physicians' Availability to See Drug and Device Sales Reps," SK&A Information Services Inc., released February
The Wall Street Journal's Health Blog provides some insight into David Blumenthal, President Obama s choice to be in charge of health information technology. Sarah Rubenstein writes,
As national coordinator of health information technology, Blumenthal will have at his disposal the $19.5 billion dedicated to health IT in the recent economic-stimulus package. He has headed the Institute for Health Policy at Massachusetts General Hospital/Partners HealthCare System in Boston.
We took a look at a New England Journal of Medicine article he penned in 2007 with Jonathan Glaser, CIO at Partners HealthCare, called “Information Technology Comes to Medicine.”
The idea of health IT transports some enthusiasts “to almost a dreamlike world of health care perfection in which the work of doctors and the care of patients proceed with barely imaginable quality and efficiency,” they wrote. But for many doctors, especially those in solo or small practices, it “conjures a very different image — that of a waiting room full to bursting, a crashed computer, and a frantic clinician on hold with IT support in Bangalore.” . . .
Sunday, March 22, 2009
I am sure that many of your students are on facebook - perhaps even during your class. Apparently students start on facebook at quite young ages and some doctors are considering whether there are some downsides. Kari Henley at Huffingtonpost writes,
For over 25 million youth, Facebook is replacing email as "the" way to communicate, and parents are often left in the dust and wondering is it safe? What age can kids safely have a Facebook page? Should they insist to be their "Friend" and monitor their endless chatter? . . . .
One day, a call came from the principal informing Jill and her husband, their middle daughter was being given in-school suspension for creating a Facebook group used to make fun of another student. Called something like, "Eric is a Hairy Beast," the group quickly filled with loads of kids making fun of a quiet Armenian boy, uploading cell phone pictures of him and becoming more brazen by the day.
These kids are "A" students, and far from brats; but most are not cognitively developed enough to recognize their behavior is hurtful to others. According to Lisa Ott, the Youth Empowerment Coordinator at the Women and Family Life Center, this is on target with research in adolescent brain development.
Kids get into trouble with sites like Facebook and MySpace because they are too self-centered in their overall development to understand the impact of what they are doing, she said. Middle school age children are the most susceptible to cyber bullying, and high school students most likely to use poor judgment in giving out information.
Dr. Jay Giedd is the chief of brain imaging in the child psychiatry branch at the National Institute of Mental Health, and an expert in adolescent brain development. His research shows the brain is not fully developed at age 12 as was believed, but reaches full maturity in our mid-twenties. Adolescence is a time of profound brain development, surpassing that of toddlers. The area of the pre-frontal cortex develops last, which is in charge of higher reasoning and understanding consequences. The emotional centers of the brain that control happiness, fear, anger and sadness often over-compensate, and can be 50% stronger during adolescence.
I set about interviewing scores of parents with children from elementary to high school, asking their opinions about Facebook and kids. While most felt it was a relatively safe place for kids to connect to each other, many expressed concern over the obsessive nature of these sites. Designed to be "sticky;" a site is deemed successful the longer it entices you to stay on, yet these hours are replacing other activities critical for healthy development.
A child's brain reaches its full size at age six and the gray matter is actually the thickest around age 12. Remember how the world was full of possibilities at that age? Because it truly is. After this stage, the brain begins to prune back gray matter and the phrase "use it or lose it" becomes key as certain brain cells die forever. The skills your child learns during adolescence; like sports, dancing, music or academics become hard wired. Other skills that are not being used will fall away. . . . .
Most kid's today don't have a local bowling alley or soda shop to hang out, like the baby boomer generations had. They also aren't allowed to play outside until the street lights come on as recent generations enjoyed. Hours of skipping rope, climbing trees and building forts is replaced with the tap tapping of tiny keyboards. The cyber playground has replaced the physical one, for better or worse. It is our job as parents to make sure their developing brains know how to do more than move a mouse around a keyboard and encourage more face to face social time. . . .