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Remember back in the 1990s? Clintons were in the White House. Bushes wanted to be in the White House. Health care reform was fresh on everyone’s mind. As the French say, plus ça change, plus c’est la même chose, I guess.

The care delivery reform vehicle of the 1990s was to be Health Maintenance Organizations. Not particularly liked by physicians, these were groups of physicians and non-physician providers (hospitals and other health care entities)  who were tied by a common goal of delivering quality care at low cost. The problem is the definition of quality on the part of the HMO (low use of services that were not proven to be effective) was not the same as that of the patient (immediate access to services felt to be necessary by a prudent lay person).

In 1998, 3200 graduates of US medical schools went into Family Medicine.

The HMO movement eventually receded, as a consequence of consumer and physician revolt, although some remained (Kaiser and Group Health Puget Sound are the most well known from that era). For most Americans in the ensuing years, health care consumption was considered a matter of personal choice and, as Americans, we opted for convenience and technology. Insurance companies obliged us by limiting out-of-pocket cost. One could eat at the health care buffet and it only cost a couple of dollars.

As  physicians, we opted to provide these services in as efficient a manner as possible, with this efficiency being manifest as immediate access for folks with insurance. What happened was fairly predictable. Physician salaries skyrocketed. Health care inflation soared. Consumption was increased in areas of surgical procedures and high cost medications. Use of opiates such as Lortab dramatically increased.  If the analogy was one of restaurant dining, it is as if everyone with insurance in America got a free dining card with unlimited dessert.

For those without insurance (about 15% of adults under 65), care was not readily accessible unless they had significant cash to spend. Their dining card allowed them to stand by the dumpsters and wait for table scraps.

In 2004, only 1100 US grads went into Family Medicine.

Medical students in this country started talking about the ROAD to success, getting a position in a Radiology, Ophthalmology, Anesthesia, or Dermatology residency. Relatively easy work, really high pay. The pastry chefs of medicine.

American medical school in 2006 stood ready to respond to this new market reality, as encapsulated in this report from the era. They recommended a strategy of increasing enrollment in medical schools by 30%, supporting it with evidence of an aging workforce and the fact that physicians were not located where they needed to be (areas of shortage). In addition, they pointed to increased demand for more convenient access by an aging population.

If you fill the bucket to overflowing, they figured, student physicians could not help but go to places of need and select specialties of need. The market would sort things out. The aging population would get the doctors they needed, more Americans could catch the brass ring of “my son/daughter the doctor,” and we could continue to allow the market to set the tone. Or, to use the restaurant analogy, everyone who wants to be a pastry chef can be, and certainly someone will want to clean the dishes.

Did it work? We have increased the number of medical students from 14,000 in 2006 (the year the AAMC decided that the answer was to increase the number of doctors) to 22,500, an increase of 66%. The number of positions offered for training after medical school has increased from 24,000 to 27,000. Of those new US grads, the number electing to do radiology is up 200% and anesthesia is up 300%, Physical medicine and rehabilitation (one of the “new road” specialties) is up 300%. Family medicine, the specialty that goes to rural areas, the most rapidly aging specialty—how are we doing? Up 20%. The rest of the Family Medicine training slots? Filled by folks who went to medical school  in other countries

American students, it seems, are betting that we as a country are going to continue to allow people to eat unlimited dessert and they all want to be the pastry chef. So much for allowing our country’s workforce policy to be set by 25 year-olds. Heck of a way to run a restaurant.

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Resident: Hey, I diagnosed a black child with thalassemia today

Attending: Oh, really

Resident: Yeah, the funny thing is it was picked up on the newborn screen. Child and parents are obviously of African-American decent. They are not aware of any Mediterranean ancestry.

Attending: And that’s why we shouldn’t take race too seriously when screening folks for disease.

Medical learners are taught from an early age to speak clinically in a very distinct language. We call the method of communication regarding patients a “presentation” and typically the pattern is age, race, sex presented with symptom constellation. The story then goes on to recount pertinent positive and negative information, past medical history, family history, social history, physical findings, and ends with the clinician identifying the diagnosis and plan. A lot of information is distilled to keep these presentations concise. The shorthand starts with the age (if the complaint is chest pain, heart attacks don’t occur in 14 year olds, for example) and sex is an important component (a man with “blood on underwear” has fewer moving parts “down there”). Race has always been included in the construct. What goes with race?

Unlike veterinarians, we physicians only have to deal with one species. I have to admit, I almost always assume the entitiy being presented by the learner is human. Having said that, within the homo sapien species there is a lot of genetic variation. If I know something about their family (the patient’s mother and father both have sickle cell trait) then I can draw a conclusion about the patient (this person has a 1 in 4 chance of having sickle cell disease). Otherwise, unrelated people have 3,000,000 distinct variations and people of the same “race” differ by as much as 85% from each other. What of the other 15%? Turns out less than half of it can be traced to similarities in skin color, hair form, and nose shape. In other words, what we see as commonalities that track together (skin, hair, and nose) are for the most part the only things that track together. Diseases tend not to cluster based on these, even less so given our current patterns of population movement. Biologists abandoned the construct of “race” for plants and animals a long time ago, because of a lack of utility. The concept of different races, itself, dates from the fifteenth century when, in response to the Catholic church‘s new “anti-enslavement of humans position,” King Alphonse of Portugal sent ships into Africa and found folks who spoke no European or Arabic tongue and had different skin, hair, and noses, so were obviously NOT human and therefore enslaveable in the eyes of the church.

The  problem with using (skin, hair, nose) to categorize people medically is that it misleads. A tragic example of this occurred in the south. Several physicians, including John Searcy of Mount Vernon Hospital in Alabama, noticed a cluster of folks with a distinctive skin rash beginning in 1906. Now known as pellagra and due to a deficiency of nicotinic acid in the corn-based diets of poor people (a byproduct of the introduction of modern agricultural methods to corn harvest), it was proven to be a consequence of poverty and inadequate nutrition by 1912. However, despite the elegant proof, the deaths continued because of the insistence of leaders in the field that it was clearly an inherited condition because it tended to run in poor black families. Coincidentally, so did poverty.

By continuing to include race on the front end we perpetuate the myth of causation instead of using it to identify groups that need special attention. Per the new England Journal:

It is indisputable that social perceptions of what a person is or is not influence the availability, delivery, and outcome of medical care. It is incontrovertible that these perceptions apply with dismaying regularity to black people and other minorities in the United States. And it is undeniable that lifestyle, socioeconomic status, and personal beliefs are powerful influences on health. But these are matters of morality and culture, and we must clearly distinguish them from the biologic aspects of race-based medicine — from the danger of attributing a therapeutic failure to the patient’s “race” instead of looking for the real reason.

When this article was written in 2001, there were 1300 articles published containing the search terms “Negroid race” in the previous two years. In what is clearly an improvement, there have only been 700 articles in the last two years,

What we know is that (skin, hair, and nose) is at best an incomplete marker for geographic genetic origin, which might be a useful clue for certain diseases. In this country, we know that it is a marker for poverty and oppression, which does seem to be correlated with disease. Instead of Black, White, Hispanic, maybe I’ll make the learner say something to the effect of “This 52 year old ‘manual laborer who lives in a bad neighborhood among drug dealers and has to sleep in his bath tub for fear of being shot accidentally’ female comes in for high blood pressure and headaches.” Too long?

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Childhood vaccines are one of the great triumphs of modern medicine. Indeed, parents  whose children are vaccinated no longer have to worry about their child’s death or disability from whooping cough, polio, diphtheria, hepatitis, or a host of other infections.
Ezekiel Emmanuel

If you give us a safe vaccine, we’ll use it. It shouldn’t be polio versus autism. Jenny McCarthy

One of the earliest choices parents have a chance to make is one of whether or not to have their child “get shots.” On day one of life, the medical system is mobilized to prevent Vitamin K deficiency bleeding and liver cancer in the child. For 90% of parents, the response is “Thank you.” For 10% (but a very vocal and increasingly evangelistic 10%) the answer is “could we wait a little while?

Why do they want the delay? Most blame it on a general distrust of the “medical-industrial” complex and a lot of conflicting (and overwhelmingly incorrect) data on the internet regarding vaccine safety. I suspect a large part of the problem is our inherent inability to work with probabilities to understand health risks.

First is our conviction that because we can see a relationship we can extrapolate a cause. Take polio and ice cream. Setting aside the crazies who deny that polio ever existed, there was a time (1952, to be specific) when 50,000 American children came down with paralytic polio. Several folks quickly identifies a striking relationship between ice cream sales and the peak of the polio epidemic. Ice cream was banned in several states before it was determined that summer was the common factor. It is flawed observations like this (leukemia and Vitamin K, autism and MMR vaccine) that have led to some of our problem. Oprah, in a nod to allowing personal observations to be treated as fact, brought on Jenny McCarthy and treated her as an expert on autism because she had “mommy instinct…. She knows what she’s talking about.”

Second, and perhaps more problematic, is our inability as physicians (and a society) to communicate the consequences of a delay. Vitamin K deficiency bleeding, for example, is only a problem very early in the infant’s life. Delaying the shot (only the shot is effective) beyond 2 months of age renders it worthless. You have already placed a bet on your child’s life (or at least risked his or her future ability to function), reducing his or her ability to pass kindergarten by 1:10,000. So what, you say? By making children get out of the pool when there is lightning over a lifetime, the risk of dying of a lightning strike is reduced by approximately the same amount (1:12,000). Why is this? I suspect the difference is folks see the damage lightning causes to trees and fuse boxes so the risk to them is much more real. Who knows, though, maybe there are anti-lightningers as well.

According to the article on vaccine delay, approximately 50% (9 minutes of the 18 minute visit) of the face-to-face time is spent discussing vaccination instead of other, more pressing issues of development and parenting. Brochures alone are not helpful in speeding up the discussion. What we as health professionals need to do is change the discussion. First, we need to be frank and truthful with the parent provide factual data and address the parent’s fears. Parents need to catalog their fears going in but need to be open minded to evidence that these fears are unfounded. Secondly, we need to address risk. Third, the use of motivational interview techniques might help clinicians to get patients to better verbalize their concern.

So, parents, you need to learn to be just as skeptical of the “interwebs” as you are of “big medicine.” Doctors, you need to understand that parents will do the right thing (witness the lack of anti-lightningers) but they gotta believe.

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Parent: My child had a fever last night to 102 degrees and isn’t taking in anything. He’s one year old tomorrow

Me (looking at what appears to be a very ill child): Does your child have any other medical problems? Are his vaccinations up to date?

Parent: We were waiting until after his first birthday. We were afraid of the vaccines.

germ theory n. The doctrine holding that infectious diseases are caused by the activity of microorganisms within the body.

The local web log decided to weigh in on the vaccination controversy last week. In an article that presented both sides equally weighted, several physicians were quoted as imploring their patients to follow the vaccination guidelines. Speaking against vaccination, Michael Bucknell, DC, BS was interviewed:

Bucknell said that many parents who choose not to vaccinate their children don’t just stop at reading one blog. “I’ve never met a parent who heard one study and said I’m not going to do it,” Bucknell explained. On his business website, Bucknell has listed numerous articles he cites in his decision not to vaccinate his sons. He also said his oldest who is 10 years old was sick for the first time in his life recently.

I really don’t want to litigate the germ theory of disease in this space though it turns out there is a long history in chiropractic thought, beginning with Palmer, of disbelief of germs as a causative agent and thus vaccination as a mechanism of prevention. Let’s concede that although not all human disease is caused by germs and not all exposure to a germ leads to disease, there is a lot of overlap between germ exposure and diseases linked to the germ. For those of you who are unwilling to concede this, you can stop reading here and move onto this article. If you have doubts but are “germ questioning,” here is a very nice article about why your personal observations (I smoke and don’t have cancer) often conflict with empiric evidence.

Now that they’re gone, let’s address the broad issue of vaccine safety and the more narrow issue of what the kids won’t catch. First, to the broad issue of vaccine safety. Turns out over half of parents have such concern with a quarter of them specifically thinking the vaccine will increase their child’s chances of being autistic. As the media clearly is unwilling to pick sides on this, let me help (thanks to the American Academy of Pediatrics):

Almost every vaccine contains an immune stimulator (antigen) in a liquid (adjuvant). If you are worried about the adjuvant having mercury – the type of mercury found in thimerosal is  ethylmercury which is broken down and leaves the body very quickly and has NEVER been shown to be harmful. Because of parental concern, however, anything that contains the word mercury has been removed from almost all vaccines given to children (some influenza preparations are the exception).

If you are worried about the adjuvant containing aluminum (used to boost the effect), there is less aluminum in the shot as there is in a weeks worth of formula or breast milk. We need it to live.

The vaccines work by exposing the body to a part of the germ, allowing the body to develop an immune response the first time it is exposed. Many people are concerned that this “revved up” immunity leads to certain disease, specifically autism. The initial autism correlation was based on a bad study where scientists lied, a study that has since been retracted from the medical literature and described as an “elaborate fraud.” There have subsequently been A LOT of studies that fail to show any correlation.

Lastly, many parents worry about “why so many shots?” Through vaccines, we protect against 14 diseases. To do that it takes a lot of shots, given that it takes about 3 shots 6 months apart to confer immunity to a specific disease. Why so young? Many of the diseases that kill children occur prior to the child turning 2. In perspective, however, we expose the child to 150 antigens over the entire schedule through the age of 2. That same child, eating doodle bugs outside, is exposed to up to 2000 antigens a day.

As a medical student, I cared for children who became seriously ill from Haemophilus Influenza B. It affected approximately one child in every 1000 and in New Orleans we would almost always have 2 or 3 children in the pediatric intensive care unit on a ventilator because of it. Of those, one in 10 would die and about 1/3rd of the survivors would be deaf or neurologically devastated. The HIb vaccine was introduced into the vaccine schedule in 1989. With vaccination, the occurrence of the disease is for all intents and purposes, 0. I haven’t seen a case in 25 years. This is why I believe in vaccines. What can I do to further convince you?

My wife: Why is Obama making people buy insurance policies that cost 8% of their take home and pay for “not much”

Me: Don’t blame me, I voted for “single payer”

My wife is involved in the enrollment process for the Affordable Care Act. Last year she enrolled many folks who were grateful for their newly found access to health care. This year she is finding a that many folks didn’t pay for health insurance previously because a) they are reasonably healthy and b) they realize that they are paying for, to coin an expression, crap.

What her clients, and everyone else in America, is painfully aware of is the following (complements of Dissent Magazine):

In America we spend a lot of money and get worse outcomes than folks who live in other countries. Some of our excess mortality is due to car accidents and gun violence but there is general agreement that even once that is accounted for, we don’t get our money’s worth. Why?

As a rule, we pay more than our peers for the same health care goods and services (especially drugs). Much “health spending” is wasted on administrative overhead, on marketing, and on the important business of figuring out who is insured and who isn’t. And that spending is starkly uneven, lavishing services on those with good insurance coverage and bypassing those without.

Here in Mobile, we finished celebrating Mardi Gras today. This is, in the words of my son, a very weird celebration. For 3 weeks, people eat, drink, and dance to excess. The streets are filled with vendors that sell such delicacies as fried Oreo cookies. The parades themselves feature folks throwing moon-pies by the thousands to the crowds. Today, tens of thousands of folks were out today cooking lots of meat over open flames and drinking lots of adult beverages.

Today was Mardi Gras day. It features a parade, the Knights of Revelry, with the lead float featuring Folly who, using pig bladders, calls attention to our excesses.

Mardi Gras 2010 096Then, at the end of the day, Folly reappears being chased by Death.

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Legend has it that, at the end of the parade, Folly wins out. However midnight invariably comes and Folly is put away for another forty some-odd weeks.

As my wife has discovered, we have been throwing the equivalent of a “carnival” diet for healthcare. We throw a lot of care at the wrong people and not enough at the people who need it. As a consequence, we are now requiring folks to spend up to 8% of their income or risk a penalty.

Here is Mobile, after today, moonpies will no longer fall from the sky. One has to fry ones own Oreo cookies if he or she has a hankering. The parade barricades go away. Perhaps people will demand more disciplined health care spending as well.

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Me: Ms G, you have atrial fibrilliation and a lot of other medical problems. That means that your heart can form blood clots that go to your brain It is REALLY important that you take the blood thinner the cardiologist put you on.

Ms G: I know but he gave me this Elliquis and I just can’t afford it. My Blue Cross charges me $140 a month for the medication and that’s just too much

Me: There are much cheaper alternatives. Warfarin, for example, can be used very safely and keep you from getting a stroke.

Ms G: He never even mentioned that to me. Can you talk to him?

When this happened this past week, I was a little irritated. Ms G is not the easiest patient to care for and now I was having to deal with a problem not of my making. After making several phone calls we switched the Elliquis ($275 a month, $140 out of pocket to my patient) to warfarin ($6.50 a month plus $24 in monitoring costs, less than $10 a month to my patient) and everybody left happy (and late). Eliquis and other expensive blood thinners offer only a marginal improvement over warfarin and they do it in a very expensive manner. They reduce of the risk of stroke over 3 years from 16 stokes per 1000 people treated with warfarin to 12 stokes for people taking the newer medications. Of those 1000 patients, an extra one (2 vs 3) on warfarin will have a major bleeding problem. While an advantage, my patient chose not to trade $1200 in food money to do this and instead made the decision on her own to triple her risk of stroke (10 strokes per 1000 annually in those untreated with atrial fibrillation and her other conditions) by not taking anything. My patient is now on warfarin and presumably much better protected from having a stroke. Why was my patient not offered the opportunity to make a choice between the new improved method OR the tried and true method?

May have had something to do with marketing. As was pointed out last night, Americans have an expensive ($330 billion) prescription drug habit. The habit not only pays for the pills (a very small part of the cost) but also the payments to doctors who do the “education” of their colleagues. In 2013 this education cost Americans $24 billion, with marketing accounting for more than research in 9 of 10 companies. In the words of John Oliver “Drug companies are like high school boyfriends: they are more interested in getting inside you than in being effective once they are there.” Bristol Meyer Squibb spent an estimated $20 million in 2013 to “educate” physicians regarding the advantages of Elliquis over warfarin in stroke prevention, with about $15 million going to physicians to extol its virtues to other physicians. I don’t know if that was the reason for the oversight. To be honest I suspect in my patient’s case it was mostly ignorance of my patient’s social situation by the cardiologist that caused my long day.

At least my patient didn’t die from an overzealous sales force. Every day, 46 people die of prescription narcotic overdoses in the US. In Alabama in 2012 there were 140 narcotic prescriptions written for every 100 people. We really don’t need folks selling doctors on selling more narcotics. However, in 2012 a potent narcotic (Fentanyl) was introduced in a sublingual spray to compete with others similar preparations (Fentora and Actiq). These medications typically have, as their very specific indication (the reason to give to a patient), cancer pain not responding to around the clock narcotics. Insys, the company that makes Subsys, spent an estimated $6 million to educate physicians about this drug in 2013. I have to admit, until I read the Propublica article, I had not heard of it. As I don’t treat many patients with intractable cancer pain, that did not particularly surprise me. They only spent $44 a meal to educate 5,000 physicians. They did pay for 775 educational events (paying a physician $2,500 to talk about the drug every time) and hired 189 consultant physicians at $2,370 each. I guess they had to get the word out. Problem is they were and are getting the word out to the wrong people. Less than 1% of the prescriptions were written by oncologists. The product was a high potency narcotic of which there were already others on the market (a “me too” drug):

The former sales employees said that while the company targeted some oncologists, it placed more focus on high prescribers of competing products like Actiq and Fentora, regardless of whether those doctors treated cancer patients. They also said they were trained to mention the restriction to cancer pain at the beginning of the sales pitch and then to move on to a more general discussion of “breakthrough pain” in the doctors’ other patients.

Not only did Insys not worry about its drug getting into the wrong hands, it kind of counted on it:

Comments from a Wall Street analyst underscore that view. “As Subsys grows more mature, we expect the number of experienced patients to grow,” Michael E. Faerm, an analyst for Wells Fargo, wrote last year in a note to investors. “As the experienced patients titrate higher, the average dose per prescription should increase.”

The company used physicians who had problems with the DEA as their speakers and unorthodox methods to motivate its sales force. A cursory review of the Opiophiile forum reveals that their product is a success, with many addicted individuals enjoying the convenience and simplicity of the medication, with some even ingeniously discovering they can use it intravenously…just like heroin. Also the boards attest to the effectiveness of the marketing strategy.

Shelley, my doctor recommended it to me pretty much as soon as it came out. He said that the company that makes them wanted him to be a representative for them or something like that.

No wonder sales have increased 400% in the most recent quarter over last year and people are bullish on Insys’s prospects. in fact, investors only got skittish when a physician in Michigan who accounted for 20% of the drug sales lost his license. Fortunately for investors, their “medical marijuana” product is about to come to market to broaden the Insys portfolio and the market cap is back up.

Don’t get me wrong, I am by no means anti-medication. In fact, only 30% of people who would benefit from warfarin or related blood thinners receive them in the correct dosage and we need to work to use this inexpensive drug more effectively. I would personally prefer to find a different way to get the Opiophile readers their fix (with entries such as “Fentenyl patch, shootable” I am concerned their might be a lot of misuse in that community). Most importantly, as a profession, let’s stop shilling for Wall Street. I’m sure they’ll do fine without us.

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Remember the song, “We’re # 37“? It came out in 2009, the beginning of the debate about the ineffectiveness of the American healthcare system and the need for change. The video went viral, more because of the catchy tune and cute visuals, I’m afraid, than for the message. Here we are 6 years later and even with the Obamazation of health care our system is still last in the industrialized world. We still do not offer access to all of our citizens (witness the 24 states that deny access to the working poor), Our system remains very inefficient with 30% of spending wasted on inefficiency and unnecessary care. We deny people access to measure proven to extend lives and do so in a manner that punishes those of color disproportionately. Worse, we do it in a manner that costs twice as much as other industrialized countries, with most of that money coming from taxpayers.  .

As a part of a class I am taking, I have been reading a lot about change management. This weekend, I read John Kotter’s book Leading Change. In this book he identifies 8 components necessary to change an entrenched system in the business world:

  1. Establishing a Sense of Urgency (people need to sense that the platform is on fire before they jump into the ocean)
  2. Forming a Powerful Guiding Coalition
  3. Creating a Vision
  4. Communicating the Vision
  5. Empowering Others to Act on the Vision
  6. Planning for and Creating Short Term Wins
  7. Consolidating Improvements and Producing Still More Change
  8. Institutionalizing New Approaches

Why are we still last? It appears that we skipped the first step. Most people never use healthcare at all. thus they are unaware that the platform is burning. Or, even if they do, it is for an urgent problem (my throat hurts, I have a cough) and our system is really good at getting folks in and out for self limited problems in a very expensive manner ($111 to tell you “It’s a cold, live with it“). For the 20% who need our system a lot, the system has moved most of the costs to the taxpayer, so the true costs are hidden. Of course, this is after the family has bankrupted themselves but the expression “blood from a turnip” comes to mind.

Turns out that part one of the Obamazation was “getting all people access” and that wasn’t even in Kotter’s book. Part two, “transform the system”, started last week. Sylvia Burwell, secretary of Health and Human Services, announced last week a series of sweeping Medicare payment changes.  In effect, the platform has been set on fire. The changes moving 50% of the money from fee-for-service to quality by 2018 with an interim goal of 30% by 2016. What does this mean?

[The adminstration] plans to tie 85 percent of all Medicare payments to outcomes by the end of 2016 — rising to 90 percent by 2018.

A subset of those payments — 30 percent in 2016 and 50 percent in 2018 — will have to be part of what the government calls “alternative payment models.” These are contracts where groups of doctors and hospitals and pharmacists — a big enough network, essentially, to cover a patients’ whole spectrum of health care needs — get a lump sum of money to take care of a set number of patients.

This, in addition to the 40% of commercial contracts that currently include a value component, means that over half of all dollars in health care will be contingent on quality. Is that smoke I smell?

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2645472-moon1“To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications.”

—Louis Pasteur

Henry “Moon” Mullins was the founding chair of the department of which I am now the Chairman. He trained at Tulane (as did I) and was in private practice for about 20 years in Fairhope Alabama when he got a call from Fred Whiddon, the founding President of the University of South Alabama. Dr Whiddon wanted to see if he would consider leaving his practice to create a Department of Family Medicine in Mobile, which he did. When I met him, in 1991, he was in 64 and had just completed a sabbatical studying medical infomatics at the National Library of Medicine. As a resident and later as junior faculty, I would have long discussions with Moon about how to get  “docs” to practice based on best practices rather than using techniques and information obtained during training (regardless of how many years ago) or for better or worse, from pharmaceutical reps.

In that discussion, we would often mention the problem of diffusion. From an article in 2006:

Studies of dissemination of evidence-based guidelines (aka, consensus statements) suggest that awareness varies widely across medical subspecialty, with awareness ranging from as low as 20% among cardiac surgeons to 90% to 95% among obstetricians.17 The dissemination gap for clinical research also has a time component. A review suggested that it took an average of 17 years for 14% of original (i.e., discovery) research to be integrated into physician practice.

17 years seemed to me like a very long time. Why so long? Many people my age have stained teeth from tetracycline, a miracle antibiotic that was introduced in the 1960s. For that antibiotic, it wasn’t 17 years but 17 months before 90% of physicians were using it. The combination of its remarkable effectiveness and peer pressure from early adopter colleagues was enough to overcome physician inertia. Many discoveries though, such as the life saving effect of beta-blockers for a year following a heart attack, are not given to all eligible patients even today, more than 20 years after the data was definitive.

Today, appropriate beta blocker use varies regionally from 68% to 92%. What is surprising is the factor that predicts the best who will get the appropriate medication: Tractor use in 1940.

The introduction of hybrid corn in the 1930s and the introduction of tractors in farming was not via a disruptive innovation model. The first states to have over 10% of farmers planting high yield corn and using tractors? Illinois and Iowa in 1935. The last states (1948)? Alabama and Georgia. Being a “late adopter” state for these technologies correlates strongly with being a late adopter for the use of beta-blockers after a heart attack. For example, Alabama was last to adopt tractors and to adopt beta blockers.

What set apart the early adopters? One of the factors is having folks (farmers and doctors) talk to each other in informal settings. We late adopters need to pay more attention to having quality information exchange among health professionals. Another is that, educationally, a rising tide floats all boats. A better educated populace demands better care. Lastly, innovation likely didn’t occur because it was more profitable to wait. Second-mover advantage, risk aversion, and uncertainty are powerful de-motivators. We need to change the incentives such that physician are paid to do the right thing.

Moon is now 86 and calls the department every now and again to check on us. As a department, we continue to work on ways to encourage physicians in Alabama to “do the right thing”  and overcome our historic tractor disadvantage.

Thanks, Moon, for starting us on this journey.

140428_cartoon_054_a18174_p465According to new research by Emmanuel Saez of the University of California at Berkeley and Gabriel Zucman of the London School of Economics, the richest one-hundredth of one percent of Americans now hold over 11 percent of the nation’s total wealth. That’s a higher share than the top .01 percent held in 1929, before the Great Crash.

We’re talking about 16,000 people, each worth at least $110 million. Robert Reich

None of my patients, that I am aware of, has $110,000,000. No one I know has a private jet.

My patients are more likely to have cars that are unreliable. They get rides from strangers to get to their appointments. They catch a bus  that is so unreliable they ride all morning for a 2:30 appointment and then spend the rest of the evening getting back home. I saw a patient last week who had kept her child home from school for a week with asthma in part because she couldn’t get a ride from her house and there is no bus that goes out that far. Perhaps a jet would have helped but I doubt it.

What does help my patients is Medicaid. About half of the folks that we see have Medicaid. In Alabama, as I have said before, one needs to be VERY poor to qualify for Medicaid, so these are folks that have a lot of other problems associated with poverty as well. My residents and I spend a lot of effort working around transportation issues, dysfunctional family issues, and other “social” issues. At times, the task seems overwhelming.

Referred to as the social determinants of health, this term describe “the array of complex forces that shape and influence the public’s health, often out of clinician sight. These include poverty, income inequality, lack of access to affordable and nutritious food, lack of educational and employment opportunities, violence and racism.” In a recently completed well designed study, investigators showed that access for poor people via Medicaid leads to higher wages, fewer arrests, and a greater likelihood of college graduation. These things in turn lead to better health. Other studies are showing that permanent supportive housing for folks suffering from mental illness goes a long way to reducing the cost to the public of these individuals. People who live in food deserts are more likely to be poor, obese, pay more for healthy food, and make unhealthy choices.

We do as much as we can in our exam room but me, my residents, and my patients
need your help. First, Medicaid is increasingly shown not to be a “broken system”  but life saving to those in need. Support expansion, especially here in Alabama where many are one illness away from bankruptcy. Secondly, while many things contribute to poverty, substandard housing and expensive, unreliable transportation contribute the most. Support policies that mitigate the effect of these such as housing subsidies and transportation alternatives. Third, obesity and related diseases (heart disease, diabetes, arthritis) are clearly related to food policies that benefit agri-business. Buy local and support those who do as well as supporting policies that increase access to healthy food. Lastly, educational attainment predicts economic success with college graduates earning double that of non-college graduates. Support policies that lead to better access to education.

Also, if you are in the top 0.01%, you could give up your private jet and give the money to our residency. Please contact me off-line for this one.

leo-cullum-expert-witness-new-yorker-cartoon1“Childbirth is something that is primitive, ugly, nasty, inconvenient,” Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo, said. “It takes long, and the idea is we have to make it fast. It’s impolite for doctors to leave cases for the doctors on the next shift–there’s a sense that you need to either accelerate it or do a C-section.”

From an article about C-section rates in Brazil

The World Health Organization has decided that about 6 out of 7 babies should be born “naturally.” How do they know this? Mostly, by making educated (and some less than straightforward) guesses. Fact is that as we doctors have medicalized childbirth, we have complicated the choices women have to make, made childbirth less convenient, and not really improved outcomes all that much. Witness Brazil, where the c-section rate is almost 50% and the maternal mortality rate is 69/100,000 births,  The best country for mothers surviving childbirth is Belarus, where only 1 mother dies per 100,000 births and where 4 out of 5 mothers have a vaginal delivery. Here in the United States, by comparison, 1 in 3 mothers get a c-section, maternal mortality is 28/100,000  and for all we spend we are still #62 in maternal mortality, between Korea and Malaysia.

One school of thought is that all of these c-sections are at least resulting in healthier babies. If only that were true. Although the statistics for infant mortality are a little confusing (some countries don’t count babies below a certain weight and others do), Brazil should have a really low rate with so many of their mothers going to section. By their count, about 12 out of every 1000 neonates die, twice that of America (best is Luxembourg at 1/1000, 3 out of 4 delivered vaginally).

If a high number of c-sections are not particularly good for the mother or the baby, why do so many get done? The National Partnership for Women and Families has debunked some myths and identified some real problems. First the myths:

1) “I want my baby on Tuesday” – Although we would like to believe that consumer choice has something to do with it, only 1% of women who have primary c-sections (a first baby born via c-section) requested that it be done that way.

2) “My doctor says I’m not made for a baby to come out down there” – Though we believe that  women are getting older and more likely to have other medical problems, this is not the case. The evidence is that those women who before 1990 would have had a trial of labor, all things being equal are now being encouraged to go to c-section.

3) “If I do a c-section the patient won’t sue me, especially if things go horribly wrong” – Turns out that the medical system screws up about 1 in every 100 deliveries but only 2% of those lead to lawsuits. Turns out docs are much more influenced by who they chat with in the doctor’s lounge than by actual risk of malpractice claims.

Why so many c-sections? First, women are not encouraged to get in shape for childbirth. We are discovering that the human body deals much better with changes associated with surgery if its owner has it in good shape. This is true for childbirth as well. Women need to be encouraged to be in good physical shape at all times but especially as childbirth approaches. Second, it is important not to rush mother nature. We are finding out that waiting until after the due date to do anything is very important. Obstetrics means “to stand by” and that is what doctors (and patients) need to do. Third is that we are afraid to agree that anything but “once a c-section, always a c-section” is okay. A problem when the primary c-section rate is so high. Fourth, we tend to have a blase attitude towards surgery. We do a lot of surgery in this country and tend to think nothing of it. Obstetricians make a living at it. Along with that  is a belief that nothing bad happens in surgery. Although  c-sections are much safer than they once were, the human womb is not made to be cut open several times and have a baby forcibly removed. Lastly, doctors get paid more for doing a c-section. Less so now in terms of money (it used to be different) but much more so in terms of time (one hour for a c-section as opposed to sitting up with a woman for 12 hours) and increased opportunity cost (ability to do something else with that 12 hours). In the words of one Brazilian who was rushed into a c-section after laboring for 6 hours (less than the average labor takes by half): “He was saying, ‘I was at a birthday party, and I want this done fast because I want to go back and finish my whiskey,’” she said.

To change the c-section rate, then, women will need to take back their bodies from doctors (again). They need to be aware of what the c-section rate is at the hospital they are planning to deliver at and select a doctor and a hospital with a rate below 25%. They need to demand an opportunity to go into labor naturally if at all possible. Mostly, though, they need to prepare for labor physically and mentally. Turns out that only mothers can prevent needless c-sections.

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