Archive for April, 2013

Tuesday, April 30th 2013

Do “Better” Residencies Mean Better Physicians?

I’m not sure I believe that safety data from primary teaching sites for residencies can play large in informing medical students on the residencies they should choose.

[T]he most prestigious hospitals are not necessarily the ones teaching the most compassionate or even the safest care. Looking at how patients are treated in the last six months of life might seem like an odd way to compare hospitals, much less residency programs, but its actually a good measure of the kind of doctors residents will learn to be, and it speaks to broader aspects of the training program. Looking at these patterns of care can help medical students find the best residency programs for them — even if they’re not necessarily the “best” programs.

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Sunday, April 28th 2013

The Government Telling You What Drugs You Can Take Is A Balancing Act

What’s the substantial difference between hydrocodone or dihydromorphone or diacetylmorphine? Beyond their manmade designations. Their potential risks versus their potential benefits are difficult things to quantify. In some studies diacetylmorphine is a better analgesic than morphine; nowadays, at least in the United States, only the criminal can tell us anecdotally. The various governments of our federal republic nominally weigh the risk versus reward of all controlled substances in determining under what conditions they will allow them.

It is true that government regulatory behavior appears to influence clinical providers utilization of opiates. But considering physicians can’t even agree on the appropriate use of the opiates the government does lend them to use,

It is unlikely these standards will be developed until there is a consensus among pain specialists about opioid use for nonmalignant pain because boards/agencies have no consistent, reliable source of expert information: Pain specialists should initiate efforts to develop this consensus.

Long term opiates for nonmalignant chronic conditions remain a controversial subject. I say that despite their wide use. Many factors including many psychological and social and financial factors that favor benefit from opiates play into any improvement (or lack thereof) in such pain. And the long term benefit from opiates in a condition like chronic back pain is questionable at best despite the fact such drugs may be the only thing that seems to make your loved friend or family functional. To be fair, not as dubious as surgery itself often.

Nor, as above, is the utilization of opiates, even amongst pain specialists, standardized for such conditions. It is remarkable both the variations amongst clinicians in opiate use for nonmalignant pain and the factors that influence such use. So a belief your personal health care providers know best for your pain may be an inadequate argument against government regulation of opiates.

I’m not a fan of government regulation of opiates whether in a medical setting

My wife suffers from chronic pain…she…requires daily narcotic pain medication to manage her pain.

[...]

My wife is not the criminal. Colorado and the DEA are forcing her to live in pain as they restrict her legal access to pain relief. No one should have to watch the person they love suffer in unimaginable pain just because of bureaucratic hurdles put in place to slow illegal drug use.

…or for personal treatment or other reasons. The point of this post is the distinction is smaller than you may imagine. “[I]llegal drug use” is whatever the government says. Philosophically is there much difference between restricting the hours when you can get morphine from a pharmacy and making the very possession of heroin out of the lab illegal?

Friday, April 26th 2013

Why You May Have Less To Fear From Superbugs Than You Think

Infectious disease is the most hyperbolic of all medical fields, at least when the media gets ahold of such. Right now we are to fear a new avian influenza virus. Previously there was another avian influenza strain whose outbreak threatened the world and of course SARS and, more distantly, the ebola virus and the threat of bioterrorism. And on the periphery, as these acute threats come and go, is the persistent threat of super bugs; bacteria resistant to multiple antibiotics. Sometimes all antibiotics.

I remember my pharmacology professor in medical school claiming that within our practice lives we would reach the useful end of antibiotics. A claim, literally, that physicians would no longer have any use for antibiotics by the time I reached the end of my career.


via The Hamilton Project

Scary stuff but evidence that such outrageousness sells pharmacology in a classroom as much as it does magazines on a news stand. Time magazine a post called “The End of Antibiotics?” referencing a Guardian article along the same lines. This followed a similar 2009 scare article in Time.

And recently in the New York Times, this,

Scientists all over the globe are in a race with evolution, scrambling to understand the underlying mechanisms of antibiotic resistance and to discover new ways to fight bacteria. We must diversify our methods for treating bacterial infections and simultaneously reduce the amount of antibiotics we use, says Brad Spellberg, an infectious-disease specialist at U.C.L.A. This has led to a renewed interest in treatments from a world before penicillin.

In the United Kingdom tabloids took to tracking down individual MRSA victims and sensationalizing their stories, prompting this response from the BMJ,

Raising public awareness can be helpful, but the creation of a climate of fear among patients entering hospital is more likely to increase newspaper sales than to provide a solution.

And while that is part of the issue of the hysteria around antibiotic resistant infections, obviously media is not the sole driver of such. The director of the World Health Organization said antibiotic resistance meant “an end to modern medicine as we know it.” The Infectious Disease Society of America has this publication called, “Bad Bugs, No Drugs.” Sensational quotes.

In 2007 multiantibiotic resistant bacteria were attributed as the cause of 25,000 United Kingdom deaths a year. In the United States the CDC estimates that 90,000 people die from hospital acquired infections every year, a significant portion of those likely from multiantibiotic resistant bacteria. Terrible numbers, but even if they’re on the rise, they continue to pale in comparison to other health care risks and this more than 5 decades after the first great superbug came into the mainstream consciousness.

Infection continues to register weakly as a cause of mortality in the United States compared to heart disease or cancer or chronic respiratory disease or trauma or suicide even. Even when you add all the infections up; the majority of them hardly attributable to multiantibiotic resistant bacteria.

I know we spend much time focussing on the risk factors for cardiac disease and lung disease and the public health issues of such. And the media aids such, but certainly not on the order of magnitude more you might imagine such would demand considering the true risks these non-communicable diseases pose for you and me. And not with the hysteria with which media covers infectious diseases.

This is a serious problem but one that despite its growth will long pale in comparison to other public health issues. And it is not an insurmountable issue. Old therapies, new therapies, prevention are all reasonable strategies for checking the threat of multiantibiotic resistant bacteria. Any public disaster that can be anticipated with any permeance of common knowledge and with any foresight can be stopped.

To be fair, media coverage serves the purpose of informing an important step in fixing any problem but, perhaps, with some measure to the coverage.

Wednesday, April 24th 2013

Work Restrictions Mean Overworking

Dr. Pauline Chen (always worth a read in the New York Times) has a take on why the most recent ACGME work hour restrictions for residents have been largely a failure.

“Fatigue is bad, but overwork is worse,” said Dr. Lara Goitein, lead author of a recently published editorial in JAMA Internal Medicine and a pulmonary and critical care physician at Christus St. Vincent Regional Medical Center in Santa Fe, N.M.

[...]

Health care trends over the last two decades have only exacerbated young doctors’ workload. Admissions to teaching hospitals increased nearly 50 percent from 1990 to 2010; in that same period, the number of doctors in training available to do the work increased by only 10 percent. And because insurers are pushing for shorter hospital stays, only the sickest patients, many of whom require complex care, remain hospitalized.

Are residents nowadays really expected to do more than those decades ago even if they’re technically working less? Maybe the stories of those before me trekking up hill both ways in the snow to save lives are something else. Then again, I am finding time to write this blog post.

Monday, April 22nd 2013

The Two Thousand Dollar CABG

I remember reading a profil of Devi Shetty and dismissing his dream of cheap surgery as unreproducible in the West. His Narayana Hrudayalaya hospital in Bangalore India supposedly does the most heart operations in the world. He contracts with fabric companies to make his own low cost suture, trains families to perform the duties of western nurses (although such is the way in much of the world), is aided by India’s lax recognition of pharmaceutical patents and uses his huge volume to drive a bargain on medical equipment he cannot replicate in cheaper form. All of such is done on the cheap for patients with a tiered progressive pricing system that has the truly poor pay nothing and those that can afford it pay on a scale and for more comfortable accommodations.

He continues to push boundaries by opening facilities across India and one in the Cayman Islands. In a new profile, he compares his ambitions to health care in the western world,

“Near Stanford (in the US), they are building a 200-300 bed hospital. They are likely to spend over 600 million dollars,” [Devi Shetty] said.

“There is a hospital coming up in London. They are likely to spend over a billion pounds,” added the father of four, who has a large print of mother Teresa on his wall — one of his most famous patients.

“Our target is to build and equip a hospital for six million dollars and build it in six months.”

There may indeed be things to take away from Dr. Shetty’s work. Ideas about continuous operations and large volumes and standardization of processes. Here is his talk on such things to an NHS trust. But it is not wholly replicable. And isn’t merely a matter of entrenched interests or unnecessary regulation. Certainly such are major obstacles. The biggest obstacle and a foolish obstacle.

But even if such didn’t exist in western health care there are other more inherent considerations. At least one of which is that I think much of what Dr. Shetty has done has benefited from costs borne by western health care.

India and Africa and the Cayman Islands didn’t bear the development costs of those dialysis machines or heart valves that Dr. Shetty’s company is now buying in bulk. And they can’t. The technology in fifty years or a hundred years that is going to make all of Dr. Shetty’s valve replacement operations obsolete isn’t going to come from the still developing world.

That’s not to completely justify the massive difference in costs between what Dr. Shetty is doing and America. Like I said, there is much to learn from him. I agree in the specialization of physicians as technicians, of tertiarization of specialized care, of volume and of operating closer to capacity and with greater efficiency. There is probably amazing savings for western health care there. But the idea of the two thousand dollar CABG in England or France or Canada is infeasible and, to be honest, I’m not sure desirable.

Sunday, April 21st 2013

Giving Away For Healthcare

Medicaid covers a large percentage of nursing home care and it is becoming a strategy (or at least a consequence) for the elderly to give or spend themselves into poverty to become dual eligible.

Millions of consumers have only one plan for covering long-term health-care costs. It’s to spend themselves into poverty until Medicaid — the state-run health-care program for the poor — picks up the tab

[...]

Washington is making another run at the issue. Chernof and 14 other health-care experts have been appointed to a commission on long-term care, created by the tax law that was signed in January. Members include Massachusetts’ Medicaid director, Louisiana’s secretary of health and hospitals and the vice chair of AARP’s board of directors.

[...]

The CLASS act, an attempt to set up a voluntary long-term care insurance program, was included in the health-care reform law but then rejected as unworkable by the Obama administration and repealed by the same law that created the commission. “It was a catastrophe,” says Howard Gleckman, Urban Institute resident fellow and author of the book, “Caring for Our Parents.”

Medicaid as the primary funding for long term care is unsustainable. And it is becoming harder and harder to give away your assests and qualify for Medicaid.

[S]ome people give away their money and property in order to qualify for Medicaid help sooner, a practice known as Medicaid planning.

[...]

The government doesn’t want to finance long-term care for people who are sheltering assets that could go toward paying their bills. So the new rules, which took effect in February 2006, extend the “look back” period from three years to five. If an individual gives away money or property during the five-year look-back, it triggers a penalty period during which he or she is ineligible for government aid.

The penalty period equals the amount given away divided by the average cost of nursing-home care in your area. So, for example, if you give $60,000 to family members and a nursing home costs $6,000 a month where you live, you can’t qualify for Medicaid for ten months.

We’ll see what the commission comes up with but I’ll be surprised at a legitimate solution.

Friday, April 19th 2013

The Studies Are All Bad

One of my fellow residents might be a Ben Goldacre disciple except amongst all his citations in conversation I’ve never heard him reference the English Physician. I’ll call Dr. Goldacre the ‘Bill Nye’ or the ‘Neil Degrasse Tyson’ of the antagonistic medical epidemiology circle. But it’s a growing group. Amongst them as well the Greek epidemiologist, John Ioannidis.

There is a horrific set of facts about what we know in medicine.

1) Most medical research is so poorly designed that conclusions you can draw from it are…limited

2) The medical research we are conducting is low yield

3) Most medical research performed never comes to light because it fails to meet the hypothesis of those who conducted it

4) There is strong incentive to falsify results

Ioannidis has a famous paper entitled “Why Most Published Research Findings Are False,”

[T]he majority of modern biomedical research is operating in areas with very low pre- and post-study probability for true findings. Let us suppose that in a research field there are no true findings at all to be discovered.

A Huffington Post article by Dr. Ida Sim,

About 80 percent of clinical trials are funded by the commercial sector, but the commercial sector disproportionately studies drugs, and understudies behavioral treatments or older treatments that can’t be patented or profited from. When 75 percent of our medical costs are for chronic diseases that are largely due to poor lifestyle habits, where are the studies on prevention? On behavior? On effective patient-doctor or public health strategies? Where are the studies that examine the balance of benefits and harms, that guide patients and doctors on side effects and cost-effectiveness?

In England a researcher working for Aptuit is set to serve a prison sentence for falsifying lab results for a cancer drug.

Steven Eaton, from Cambridgeshire, has become the first person in the UK to be jailed under scientific safety laws.

[...]

Sheriff Michael O’Grady said: “I feel that my sentencing powers in this are wholly inadequate. You failed to test the drugs properly – you could have caused cancer patients unquestionable harm.

“Why someone who is as highly educated and as experienced as you would embark on such a course of conduct is inexplicable.”

Speaking after the case, Gerald Heddell, the Medicines and Healthcare Products Regulatory Agency’s director of inspection, enforcement and standards, said he welcomed the conviction.

He added: “This conviction sends a message that we will not hesitate to prosecute those whose actions have the potential to harm public health.”

Biomedical research is difficult to call science. What you can assume your doctor or surgeon knows about your condition is surprisingly less than you think. They will certainly act like they know and truly believe that they do but such knowledge is based on a limited amount of reliable data. In Dr. Ionnaidis’ essay there are some suggestions on making medical research better. And of course as Dr. Goldacre calls for all results of all medical research should be public. Even if that disincentivizes some research we may not be missing out on much.

Wednesday, April 17th 2013

Medical X-Rays

Nick Veasey makes art by taking x-rays of everyday, often over the counter, medical supplies. Things like band aids or bottles of acetaminophen. The images are pretty cool.

Wednesday, April 17th 2013

More On Overpaid Physicians

As if I hadn’t linked to enough journalism chiding Steve Brill for not taking on physician earnings as part of the problem with American health care. Here is Mother Jones doing similarly from last month,

American doctors are pretty well paid.

[...]

So is this more or less than US doctors “deserve”? On that score, it’s worth pointing out that most American doctors have to pay their own medical school bills, a cost that’s picked up by the government in most other countries. Despite that, it’s a little hard to argue that American doctors, especially specialists, have been squeezed to the breaking point.

Boo.

Tuesday, April 16th 2013

Doctors Are Overpaid

Steven Brill wrote a piece recently in Time called ‘Bitter Pill: Why Medical Bills Are Killing Us’ which if you have a Time subscription you can read here or, if you don’t, you can read here [PDF]. The lengthy article is worth a read and drew much praise, including from many other journalists. Ezra Klein and Matt Yglesias both took it up at the time at their respective blogs. And both, at least in part, used Brill’s article as a launching point into a subject Brill himself, careful or not, did not much broach. That subject is physician earnings. At Wonkblog, amongst many graphs on comparative health care costs, we got this,

And at Slate’s Moneybox, we got this,

[Steve Brill] doesn’t care a fig for the hospitals, which are the villains of his story. Rather he rejects Medicare expansion because if Medicare expanded, “no doctor could hope for anything approaching the income he or she deserves (and that will make future doctors want to practice) if 100% of their patients yielded anything close to the low rates Medicare pays.” It’s true that many American doctors do believe that they would be crushed if they were paid only Medicare rates. They insist they’re hard-pressed as it is, barely getting by, and practically treat these Medicare cases as acts of charity. There’s no way they could swallow those reimbursement rates without the whole system collapsing.

[...]

The last time the OECD looked at this, they found that, adjusted for local purchasing power, America has the highest-paid general practitioners in the world. And our specialists make more than specialists in every other country except the Netherlands. What’s even more striking, as the Washington Post’s Sarah Kliff observed last week, these highly paid doctors don’t buy us more doctors’ visits. Canada has about 25 percent more doctors’ consultations per capita than we do, and the average rich country has 50 percent more. This doctor compensation gap is hardly the only issue in overpriced American health care—overpriced medical equipment, pharmaceuticals, prescription drugs, and administrative overhead are all problems—but it’s a huge deal.

Now I’ve rambled on this in a tuss before. My previous commentary on such is emotional and, admittedly, applies to but a small minority of health care interactions. As the recession has shown us, much of health care is not so urgent. That said, I still stand by the gist of my original argument. I think some responses to Steve Brill’s piece, and indeed to those who would try to medianlize physician income, are making leaps of illogic.

Article’s like the one by Matt Yglesias at Slate, linked to previously and titled “America’s Overpaid Doctors,” and this Weekly Standard piece I linked to months before are examples of such.

The major mistake is that they seem to imply that the system doesn’t represent a market but then go on to argue that American physicians are getting paid above market rates. As the Slate article says early,

It’s easy to see why a health care provider is almost uniquely well-positioned to bilk you. If you don’t get treatment, you or someone you love might die. It’s a high-pressure emotional situation that makes it extremely difficult to bargain, comparison shop, or just decide to cut back.

But the starting point, almost universally it seems, for arguing against the current level of American physician earnings is that American physician earnings are vastly incongruent with some implied international market.

The conclusion; the assumption that American physician pay should be more in line with the rest of the world is loopy. It certainly isn’t effectively argued by merely comparing American physician earnings against the earnings of their international counterparts. It’s silly to say that international comparisons of physicians earnings provide an argument for lowering American physician payments, implying a market value for physicians, when the market doesn’t really exist because international physician compensation is centrally dictated.

I assert that the rest of the world’s physicians earn too little and in a less dictated market they would earn much more.

There is a massive disparity of information and at times an acuity to choices in health care that in a free market would potentially elevate physician earnings. Indeed, my previous post is dedicated largely to hypothetical situations where the above, and thus physician earnings, would be maximized in a truly free market. But to call such situations a “bilk” is ridiculous; that’s the way markets should work.

ZiyadMD has a blog with a great post on American physician earnings.

“Doctors should be among the best-paid people in society because we give them a great deal of responsibility,” says Joseph White, PhD, a public policy professor at Case Western Reserve University who studies international healthcare systems. “But we have great income inequality in the US, and doctors use the high-level group as their reference point. That means the 95th percentile is further from the average worker than in Germany or Holland. That bothers me.”

He notes that other advanced countries deliberately consider how much physicians should earn when setting payment levels, which runs against American free-market ideology. “What they come out with has to be seen as fair in terms of the overall income of doctors relative to each other and to the rest of society,” says Dr. White.

Of course, international comparisons are tricky because US practice costs, including overhead and liability premiums, are much higher, and educational expenses for US physicians are considerably greater than in other advanced countries where medical school tuition costs are heavily subsidized. But the income differential for US physicians significantly exceeds those higher costs. According to an article in the September 2011 issue of Health Affairs,[2] the income difference after practice expenses between US and British orthopedic surgeons in 2008 was nearly 5 times the difference in education repayment costs, meaning that US physicians are earning compensation in excess of what they’d need to pay back medical school debt.

I concede, and have before, that there are many things un-laizze faire in American health care and yet work decidedly in physician’s favor. Chief amongst them licensure and scope of practice issues.

And I want to note I am not disputing the earning of American physicians as compared to their international counterparts. Here you see citations for practice costs and the cost of medical education as why American physicians should earn higher. That argument is just as bonkers. I concede, despite the higher costs of practice and the costs of medical education, that American physicians earn much more than their conterparts around the world.

It isn’t that American physicians are overpaid though. It is just that the rest of the world is underpaid.