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.

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

spinal chord

I've been journaling about Vedic chant and its perplexing, strong effects on the health and well-being of my students (and on mine, too, of course).  Then, out of the blue comes last week's Sunday NYT article:  Composing Concertos In the Key of Rx:

"I broke vertebrae 11 and 12, missing the spinal cord by a millimeter... The doctor said I can't do much for you for a while, but you can sing if you like" says Vera Brandes, a researcher in the field of music therapy.  She was sharing her room with a Buddhist whose friends came and chanted daily.  After just two weeks at the hospital, an MRI showed her spine was completely healed.

According to the article, doctors at leading research hospitals are designing studies to learn how music therapy works for conditions such as depression.  Based on the assessments from these studies, one said:

Physiologically it's perfectly plausible that music would affect not only psychiatric conditions, but also endocrine, autonomic, and automimmune disorders.  I can't say music is a pill to abolish these diseases ... [but] so many pills have horrible side effects.  Music has no side effects, or no harmful ones.

 

bologna

Great new post on the Daily Beast about the shortage of hands-on, old-fashioned, family doctoring  ... alas this kind of thing was once performed by physicians who didn't need to feed their MRIs, and infusion centers with "customers". 

Fewer graduates today choose family medicine because PCPs are forced by insurers to sandwich patient after patient into bologna-thin slices of time, and they do it for far less reimbursement than their specialist and surgical colleagues.  Dr Abraham Verghese makes suggestions to remedy the problem (quite easily) by creating a quid pro quo between new PCPs requiring scholarship debt relief and the government, which has a pressing need for a "physician corps" to practice in rural and underserved areas.  

Question for the day: has the mechanized care model won our hearts and minds so much that we will refuse to consider Dr. Verghese 's simple, effective proposal ... only because it promotes an archaic style of care?  

Some of my friends have had unnecessary MRIs.  I wonder whether the choice was made heedlessly, because of underlying anxiety that might have been addressed by a truly "attending" physician.  

And I have had one (perhaps) unneeded and very expensive biopsy, so I have to make some adaptations, too.  If my OB-GYN had had the time to call me before the decision was made with the surgeon, my choice might have been different.  Indeed she tried, but by then it was too late, and it's nearly always impossible to reach her by phone to return calls.  The choice of tight scheduling is not hers to make.  I'm sure she'd like to be more available. 

To create change, there has to be a will to wean ourselves off the fantasies surrounding high-tech care: that these procedures provide certainty in diagnosis (not always) and cost effective care (not necessarily).  

We can all agree that regular screening is a boon for many conditions.  But being sliced and diced into films, slides, and images is not equivalent to receiving good medical attention.  As a nation, we need the political will to keep private insurers who profit from high tech as far away as possible from the design of the new system.  One economist described the market effects of insurers' competition in healthcare:  "Competition can sometimes fragment value ... and even destroy it."

Final word today from the good doctor:

"Health reform must take away the incentives to do to and replace them with incentives to do for the patient and to be with the patient.  As the debate heats up and the lobbyists warm to their tasks, let's listen to the patients, because they can tell us what's wrong.  Yes they can."