politics and practice based on mindfulness

Wednesday, April 15, 2009

stress tests

It was a fun morning on the Times site.  Let's do a round up of the latest craziness:

NYT Online, front page, top left column: "US Planning to Reveal Data on Health of Top Banks" -- the story is all about federally-sponsored "stress tests" designed to protect most big banks from toxic assets (created by the banks' own products divisions).  

And in the meantime, what is the "stress test" offered to the average person coping with illness in this country?  Nada.

Today's NYT Well features a parent who took his family in exile into Mongolia in order to provide his autistic son with access to nature-based therapy and shamanic healing.  Whether the healing is placebo-based or not, it seems to have worked well for the boy.  Next time you have an intractable mental disorder: M-O-N-G-O-L-I-A: it spells relief!

And we also learn today that if Americans have something more serious than chronic disease, say, cancer, insurance companies are happy to pay for chemo, but not the more expensive and more effective pill-based therapies.  Cost of a cancer patient's pill treatment: over $5k for the first month and roughly $2k per month thereafter.  No stress test for those patients either...

My motto for 2009: a commonly-used "stress test" for people, not for banks.  Preferably one designed by a caring, listening healer.

Monday, April 13, 2009

Obama & healthcare (part II): how to achieve "universal care"

As primary care doctors, what we can do to improve the health of our aging population is to take time to listen to all of the numerous symptoms reported, review medications, then decide upon necessary care and coordinate specialty care, if needed. 

This cognitive work is crucial to avoid unnecessary and costly procedures that may also be dangerous to a patient; yet, there little reimbursement for this essential aspect of care. Our system is geared toward more profitable, high-tech interventions and tests. 

Many family doctors are forced to see a patient every 5-10 minutes to support their increasing overhead.  The failure to provide quality care ends up costing the system more, because without adequate time to manage a patient’s problems, doctors send more patients to specialists where the care is more expensive.  Over 20% of Medicare patients have 5 or more chronic illnesses that require this comprehensive primary care management.

It takes only 3-5 minutes to write an unnecessary antibiotic for a cold and 15 minutes to explain why Penicillin is not effective for a cold and what other supportive medicines, herbs and vitamins may ease the symptoms. 

In the larger view, we as a country have become almost exclusively reliant on technology, prescription medications, and invasive procedures for our health.   A new vision of self-healing is needed.  

I have witnessed this new standard of care first-hand at the University of Arizona in  Dr. Andrew Weil’s Integrative Health program.  Dr. Weil trains physicians for the new paradigm, although in some ways, it represents a return to an earlier time.   His mission is to educate practicing physicians and medical residents about mind-body healing, spiritual aspects of healing, botanical remedies, exercise, and in-depth nutrition science. 

“Imagine a world in which medicine was oriented toward healing rather than disease" says Dr. Weil, "where doctors believed in the natural healing capacity of human beings and emphasized prevention above treatment. In such a world, doctors and patients would be partners working toward the same ends."

As we move away from a system that supports unnecessary interventions with little to recommend them in term of studies or evidence, we'll need to offer patients more in the way of health promotion.  So to achieve "universal care", medical school and residencies will train MDs to offer health promotion, integrative wellness, and nutrition classes, and not solely focus on disease-oriented approaches.

--submitted by Dr Deborah Campbell MD

Obama & healthcare part I: how to achieve "universal care"

I am a family physician who has been in primary care practice for over 14 years.  If you're a Obama supporter (like me) you're probably as pleased as I am that he is determined to extend healthcare coverage to all Americans.  But to achieve universal care, there are tougher challenges ahead than the obvious issues of enrollment.  

Based on what I'm seeing from day to day, we need to keep the adminstration focused on the following issues:

Shortage of primary care doctors.  MDs in my field are retiring faster than in previous times because of burnout from paperwork, and the constant struggle for documentation and pre-authorization.  Most medical students recognize this, and they are choosing not to enter the field.  They have large student loans, and are forced to choose more lucrative, procedure-oriented specialties.  No matter how common insurance coverage becomes under the new plan, there won't be universal care in the future if this trend continues.  

Routine use (and over-use) of specialty care.  Other countries where primary care is the main delivery system of healthcare have the same or better health in their citizens. We continue to be a country that expects specialty care, despite that this care is more expensive and may be more dangerous (because of more interventions that may lead to complications).

We have solutions, but it will probably take great political will to implement them:

Lighter loan repayment plans for students graduating in family practice would encourage more to enter the primary care fields.  Also, with a complete overhaul of the current reimbursement schedule, insurers should offer greater rewards for the health and wellness care delivered by primary care doctors. This will save the system even more money in the long run if we have a single-payer system. Current employer-based insurance coverages have no incentive to invest in the long-term, since employees switch jobs many times in their lifetime.

In case my post seems to be simply self-serving, here's a story to show the implications for the average patient.  One of my over-90 patients who is currently in care for coronary disease, has undergone cardiac catheterization TWICE in the past 6 months despite the fact that she and I have agreed on treatment with medicines, and not surgery or invasive stents.  The cardiologist has little incentive not to perform these tests since Medicare reimburses very well for them. 

In this situation, the cardiologist acted more like a highly paid plumber than a physician, in not looking at the entire situation and taking into account what is best for this elderly patient.

More examples of the over-use of specialists can be found in a recent New York Times article by Jane Brody: “More Isn’t Always Better in Coronary Care.” Surgical invasive management has been expanded without any data that these expensive interventions extend life for the majority of patients who receive them.

-- submitted by Dr. Deborah Campbell MD