Friday, June 28, 2013

Why Can't We All Just Get Along?

Pauline Chen, MD:

... For several years now, health care experts have been issuing warnings about an impending severe shortfall of primary care physicians. Policy makers have suggested that nurse practitioners, nurses who have completed graduate-level studies and up to 700 additional hours ofsupervised clinical work, could fill the gap.

... Analyzing questionnaires completed by almost 1,000 physicians and nurse practitioners, researchers did find that almost all of the doctors and nurses believed that nurse practitioners should be able to practice to the full extent of their training and that their inclusion in primary care would improve the timeliness of and access to care.
But the agreement ended there. Nurse practitioners believed that they could lead primary care practices and admit patients to a hospital and that they deserved to earn the same amount as doctors for the same work. The physicians disagreed. Many of the doctors said that they provided higher-quality care than their nursing counterparts and that increasing the number of nurse practitioners in primary care would not necessarily improve safety, effectiveness, equity or quality.
A third of the doctors went so far as to state that nurse practitioners would have a detrimental effect on the safety and effectiveness of care.
Optimal patient care depends on a cohesive team. The ongoing strife between NP's and MD is the antithesis of team, putting patients' interest secondary rather than at the forefront. To those wonks  and "health policy scientists," I would ask who cares for them and for their families. I'm quite sure our legislators have a primary care doctor, not a primary care "noctor."
Consider the story of the six dollar haircuts:
This is a true story about a third generation barber in a small community in the Mid-west. The shop had been handed down from his grandfather and developed not just a hair salon but more of a community center where the farmers and families would come in not only to get their hair done, but enjoy the coffee and donut bar and spend time with their neighbors sharing the news of their farms and families. This shop had grown to include 10 stylists who cut all the men’s hair and all the women’s hair in the community.
The owner’s son came home from graduate school over spring break, to find his father depressed and reclusive. Finally getting his father to share what the problem was, the father confided that there was a new, national chain that had been moving across the country, bringing in cheap hair salons into all of the different communities and driving everyone out of business. And so, even though the community had loved all of the work that he had done, the perms and the haircuts and the styles over the years, right down the street opened up this new shop. It offered six dollar haircuts. Person after person had left to go to the new low cost shop.
The father told his son, “There is absolutely NO way I can compete with $6.00 haircuts. So much of my clientele has now gone to the new shop that I have no choice but to close our shop. After three generations, we are going bankrupt. I can’t pay the stylists or the overhead anymore,” he despondently said with his hands covering his face so his son would not see the tears rolling out of his eyes.
The son said, “You know, this last semester I took a “science of success” program that was offered for extra credit in my marketing class. One thing I learned was something that Einstein said. He said that “The significant problems we face can never be solved at the level of thinking of the problem.” So, Dad, we have to find another way to think about this. We’ve got to find another way to see this. Another one of the strategies I learned may help us.”
So the son left the room and brought back a notebook and a pen. He told the Dad about “Masterminding”, a strategy introduced in the 1930′s by Napoleon Hill who had been commissioned by Andrew Carnegie to study the patterns of extremely successful people.
“Here’s what we do. We let ourselves think of any idea that comes to mind and we write it down. No editing. We get a flow of ideas for 15-20 minutes and try to get as many as possible. No idea is off limits. Let’s go.”
The father said, “Well, the only idea I’ve got is..close the shop!” The son said, “Well, you’re right that IS an idea.” He wrote it down. Then the son said, “Ok, let’s keep going.” Before long the son and the father started getting a flow of ideas and writing down every one of them, even every crazy thing that came to mind. When they finished, one of the ideas absolutely jumped off the page and they looked at each other in astonishment and said, “This just might work!” The son left the next day to go back to college.
The father implemented the idea. Within 6 weeks, not only had his drop in clientele completely returned, but the number of customers was now 11% higher than ever in the history of the shop. Do you know what the idea was that turned sure failure into a new course of increasing success?
The idea was, “Place a BIG sign on top of the shop that read,
If the predicted primary care shortage occurs, physicians will need to be ready to fix more than a few six dollar haircuts. Our patients will depend on it.

Thursday, June 27, 2013

Second Thoughts About Pain

Tara Parker Pope interviews Barry Meier -

... One of the problems with chronic pain – there’s a lot of catastrophizing around it. People think this is the way it’s going to be for the rest of their life, and that they are trapped in this horrible pain and it’s only going to get worse. There is tremendous anxiety associated with that. They not only end up taking pain drugs and strong narcotics, but they take a lot of anti-anxiety medications as well.

The whole focus on multidisciplinary programs is to get people functioning again. One of the big drawbacks of long-term opiate use is many people who take these drugs over a long period of time lose physical function. The goal is to restore physical function and to help people learn if they do have chronic pain conditions, they may experience pain for the foreseeable future, but that is not necessarily a barrier to prevent them from living a full, active life.

I'd also rethink the Pain Scale - often called the fifth vital sign. No small part of today's problem with opioids can be traced back to that moment when a symptom became a sign. 

Of course that's just my opinion. I could be wrong.

Wednesday, June 26, 2013

Cannabis Capitalism

High Times In Venture Capitalism

... Toward the end of the meeting, Lowry revealed a Leafly ad aimed at a mainstream print publication. The ad featured two residents of an upscale New York City neighborhood. A dapper businessman exits his brownstone. “While beating cancer, Ian used Blue Dream,” the copy said, referring to a specific type of cannabis. A woman on her morning run passes nearby. “Molly prefers Kali Mist to relieve pain.” The tagline: “What’s your strain?”

It looked like a pharmaceutical ad: urban professionals each using a specific strain of cannabis to address a specific need — and using it like an antidepressant or a statin. Lowry later explained the thinking. “In the early ’60s, Honda wanted to sell motorcycles to Middle America,” he said. The problem was the motorcycle’s reputation. Hoodlums and outlaws rode motorcycles. Think of Brando in “The Wild One.” “So Honda came out with a campaign: ‘You meet the nicest people on a Honda.’ ” The ads featured mothers and daughters, wealthy dowagers, even Santa Claus, all riding Hondas. Cannabis, Lowry said, is the new motorcycle.
The Privateer team loved it. “This ad could run in The Wall Street Journal or an AARP publication,” Kennedy said as we walked out into the street. “Ultimately we’re trying to create reliable, trusted products that are attractively packaged. What this industry needs is a clean American brand.”
Medical Marijuana seems a political cop-out. Unless the FDA reclassifies cannabis, doctors who sign off on marijuana cards remain in the DEA's crosshairs. Whether you believe in a medicinal use for pot or not, enough people are gaming the system to discredit the entire enterprise.  Rather than establishing a "medical marijuana" industry, governments both state and federal need to have an adult conversation over legalization. It's high time.
Of course, that's just my opinion. I could be wrong.

Tuesday, June 25, 2013

Politics Over Patients

For years, patients covered by Medicaid have still been able to see non-participating physicians, pay for services and get those physicicians prescriptions filled. Thanks to the oxymoronic Affordable Care Act, this is coming to an end.

From NY State's DOH -

"As has been reported in previous Medicaid Updates (April 2011 and June 2012),
provisions of the Affordable Care Act (ACA) require prescribers to be enrolled in state Medicaid programs to be eligible to order or refer services reimbursed by the fee-forservice (FFS) Medicaid program. This means that any practitioner not currently enrolled in NYS Medicaid must do so to continue to order or refer services for FFS beneficiaries.

Effective October 2013, prescriptions written by prescribers that are not enrolled in NYS FFS Medicaid will deny at the point-of-service. Failure to enroll will impact your patients’ ability to obtain their medications.

The Department has identified non-enrolled prescribers with high volumes of prescriptions for FFS beneficiaries. Staff members are proactively reaching out to those prescribers in an effort to facilitate enrollment in an effort to ensure that patient care is not disrupted."

"The nine most terrifying words in the English language are: 'I'm from the government and I'm here to help.'" Ronald Wilson Reagan

Monday, June 24, 2013


From the Anchorage Daily:
When the American Medical Association this past week declared obesity a disease -- a move that instantly labeled one-third of Americans as sick -- it launched a controversy not seen since alcoholism received the disease designation.
Hailed by some obesity experts as a long-overdue victory, the news from the nation's largest and most respected medical group was denounced by others who say the move fuels the stigma against obese Americans.
Fat activists promptly started the .IAmNotADisease hashtag on Twitter, and a petition demanding that the AMA reverse its position, which had nearly 1,200 signatures by Friday.
...In making the call, the AMA aims to reduce the incidence of obesity-related diseases, such as cardiovascular disease and type 2 diabetes, said AMA board member Dr. Patrice Harris in a statement accompanying the announcement.
More than 35 percent of Americans are currently obese, according to the Centers for Disease Control and Prevention.
But that doesn't necessarily mean they're sick, many argue.
"We don't see ourselves as diseased," said Peggy Howell, spokeswoman for the National Association to Advance Fat Acceptance, a 44-year-old nonprofit that works to improve the quality of life for people of large size.

Read more here:

Dr. David Katz posting on The Healthcare Blog warns of the potential for medicalization of obesity. 
Why is the medicalization of obesity concerning? Cost is an obvious factor. If obesity is a disease, some 80 percent of adults in the U.S. have it or its precursor: overweight. Legions of kids have it as well. Do we all need pharmacotherapy, and if so, for life? We might be inclined to say no, but wouldn’t we then be leaving a “disease” untreated? Is that even ethical?
On the other hand, if we are thinking lifelong pharmacotherapy for all, is that really the solution to such problems as food deserts? We know that poverty and limited access to high quality food are associated with increased obesity rates. So do we skip right past concerns about access to produce and just make sure everyone has access to a pharmacy? Instead of helping people on SNAP find and afford broccoli, do we just pay for their Belviq and bariatric surgery?

Dr. Katz goes on: 

None would contest the medical legitimacy of drowning. If you drown, assuming you are found in time, you will receive urgent medical care — no matter your ability to pay for it. If you have insurance, your insurance will certainly pay for that care.
But drowning is not a disease. Perfectly healthy bodies can drown. Drowning is a result of a human body spending a bit too much time in an environment — under water — to which it is poorly adapted.
Dr. Katz' analogy seems apt. From cradle to grave, we are drowning in a sea of calories. Perhaps now, our educators, health officials, and food purveyors will re-evaluate how we got to this point and where we go from here.
Stay tuned.

Read more here:

Friday, June 21, 2013

Another Salvo In The War On Doctors

From USA Today:

In fact, unnecessary surgeries might account for 10% to 20% of all operations in some specialties, including a wide range of cardiac procedures — not only stents, but also angioplasty and pacemaker implants — as well as many spinal surgeries. Knee replacements, hysterectomies, and cesarean sections are among the other surgical procedures performed more often than needed, according to a review of in-depth studies and data generated by both government and academic sources.

Since 2005, more than 1,000 doctors have made payments to settle or close malpractice claims in surgical cases that involved allegations of unnecessary or inappropriate procedures, according to a USA TODAY analysis of the U.S. government's National Practitioner Data Bank public use file, which tracks the suits. About half the doctors' payments involved allegations of serious permanent injury or death, and many of the cases involved multiple plaintiffs, suggesting many hundreds, if not thousands, of victims.

This is yet another salvo in a war being waged on the medical profession in this country. From the flawed statistical estimates of the IOM  report to bundled payments and pay for performance to the conflation of quality with cost to expansion of midlevel scope of practice to unfunded mandate by regulation, doctors' control over their own profession has suffered more beach erosion than the Rockaways after Sandy. Often, our organizations have been alternately befuddled, complicit and impotent. How could we have let this get so far out of hand? More importantly, what do we do about this going forward? Howard Beale's window beckons. It's time to open it.

Of course that's just my opinion. I could be wrong.

Thursday, June 13, 2013

Prenatal Screening for Down's Syndrome

Everything Is About To Change

First Trimester screening presently involves combining an ultrasound with a blood test for biochemical markers. Now a new test, involving fetal cell free DNA in mom's circulation, may supplant or modify present practice.

...An Ultrasound in Obstetrics & Gynecology study by Kypros Nicolaides, MD, of the Harris Birthright Research Centre for Fetal Medicine at King's College London in England, and his colleagues is the first to prospectively demonstrate the feasibility of routine screening for trisomies 21, 18, and 13 by cfDNA testing. Testing done in 1005 pregnancies at 10 weeks had a lower false positive rate and higher sensitivity for fetal trisomy than the combined test done at 12 weeks. 

Stay tuned.

Affordable Care Act?

Deductible of $2000? Copays of $45-$65? Wait, weren't we told that premiums on the California exchange weren't going to be so bad? It seems from the above, taken from CNN, that what that means is that instead of costing individuals an arm and a leg, they're merely going to charge a leg.