By EVAN FALCHUK

I’m in Israel, home to some of the most innovative care in the world.  Doctors here wanted to know if the high-tech tests that are an increasing part of their work help.  A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis.  As one of the doctors in the study put it, “basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued.  But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S.  American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

Instead, the answer is revealed in a comment from a Canadian doctor who wasn’t involved in the study.  According to him, the use of high-tech studies has become so “routine” that doctors need to be reminded that they aren’t a replacement for actually diagnosing the patient.

There is something more fundamental happening – and it’s happening around the world.

To understand it, look to something that is happening in courtrooms across the U.S.  Some call it the “CSI Effect,” after the TV show, CSI.  In that show, a police team uses sophisticated technology to identify criminals with almost complete certainty.  Researchers have found that shows like CSI have changed jurors’ expectations of what kind of evidence the prosecution should be able to present.

Something like this is happening in medicine.

Patients show up with the expectation that the doctor will use sophisticated technology to get a quick diagnosis.  They’re often surprised to see how it really works.  Their doctor is rushed, uses paper files, and it can often take a long time before you get a clear diagnosis.  Doctors often order high-tech tests because patients expect it.Continue reading…

By ALEX EPSTEIN

He killed the audio CD but resurrected the music industry.

Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.

Turned your hand-held into a portal to the world wide web.

Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.

Really? The practice of medicine?Continue reading…

By DAVIS LIU, MD

The New York Times recently published an article titled, Finding a Quality Doctor, Dr. Danielle Ofri an internist at NYU, laments how she was unable to perform as well as expected in the areas of patient care as it related to diabetes. From the August 2010 New England Journal of Medicine article, Dr. Ofri notes that her report card showed the following – 33% of patients with diabetes have glycated hemoglobin levels at goal, 44% have cholesterol levels at goal, and a measly 26% have blood pressure at goal. She correctly notes that these measurements alone aren’t what makes a doctor a good quality one, but rather the areas of interpersonal skills, compassion, and empathy, which most of us would agree constitute a doctor’s bedside manner, should count as well.

Her article was simply to illustrate that “most doctors are genuinely doing their best to help their patients and that these report cards might not be accurate reflections of their care” yet when she offered this perspective, a contrary point of view, many viewed it as “evidence of arrogance.”

She comforted herself by noting that those who criticized her were “mostly [from] doctors who were not involved in direct patient care (medical administrators, pathologists, radiologists). None were in the trenches of primary care.”

From the original NEJM article, Dr. Ofri concluded when it related to the care of patients with diabetes and her report card –

I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations. It’s too disheartening, and it chips away at whatever is left of my morale. Besides, there are already five charts in my box — real patients waiting to be seen — and I need my energy for them.

As a practicing primary care doctor, I’m afraid that Dr. Ofri and many other doctors are making a fundamental attribution error is assuming that somehow doctors can’t do both. She is also wrong in thinking that the real patients waiting to be seen are somehow more important that those whose blood pressure, cholesterol, and blood sugars are poorly controlled and the disease literally eats them up from the inside which could result in end organ damage to the eyes (blindness), kidneys (renal failure resulting in dialysis), extremities (amputation), and heart (coronary artery disease) and possibly premature death. They aren’t in the office and yet are suffering.Continue reading…

By EVAN FALCHUK

Conventional wisdom has it that government has lost its way. It’s out of touch and out of control. It has shut out the voices and concerns of everyday Americans. Democracy — or rather, taking the concerns of ordinary Americans into account in the democratic, lawmaking process — is a notion so farfetched as to be laughable.

But what if that weren’t true?

As a private citizen — a native Bostonian with a wife and three kids who seem to think I’m okay, a job I enjoy, and a rabid Red Sox fixation — I set off to see if I could have a say that made a difference.

And here’s the clincher: It actually worked. Really.

Here’s the setup: The state of Florida had in its law a rusty old provision that made it all but impossible for an insurance company that sold insurance abroad from having offices in Florida — even though it would not be selling insurance in the state. That law cost the state untold number of jobs and tax revenue for no apparent reason. Even Florida lawmakers from both sides of the aisle were perplexed as to how and why that initial law had come to be.

This meant American companies like mine that serve the Latin American market were barred from locating in Florida, the gateway to Latin America and home of some of the country’s highest-skilled bilingual workers.

Gov. Rick Scott, I knew from reading the papers, was keen to add jobs for Floridians. So was Insurance Commissioner Kevin McCarty. So was every lawmaker in the Florida Legislature.

So I hopped on a plane (well, lots of planes), knocked on their doors, and made my case. I explained that some simple changes to the old law would create jobs and new revenue for the state — all without spending a dime of government “stimulus.” I worked with staff and legislators on both sides of the aisle — Republican Reps. Bryan Nelson of Apopka, Carlos Lopez-Cantera of Miami, Sen. Garrett Richter of Naples and Democratic Sen. Chris Smith of Fort Lauderdale among them — to create the few brief, sensible improvements, and a few months later, the Legislature included the idea in HB 1087. It took effect this month.Continue reading…

By Dan Munro

Webster’s has a new entry for mea culpa:  A voluntary payment of $500,000,000.00 to avoid prosecution.

That’s almost a rounding error for a company with a Market Cap well north of $130 billion – but the healthcare system can definitely use the money.  I remember when some of the first estimates for widespread EHR adoption were announced in 2008.  One that was hotly contested (way too high) was $150 million over 8 years.  Safe to say – we’ve got that fully funded – with change.

Google stock actually inched up (+$3.25) so it’s safe to say investors collectively yawned. Buried in their long forgotten Corporate Information pages is this one called:

Ten Things We Know To Be True

“We first wrote these ‘10 things’ several years ago.  From time to time we revisit this list to see if it still holds true.  We hope it does – and you can hold us to that. (September 2009).”Continue reading…

By MAYRA ZILBERBERG, MD

What if medicine in the US is just like the internet? What if it is just as difficult to separate the chaff from the wheat in medicine as it is on the web?

Both the curse and the blessing of the web is its accessibility. This means that anyone’s voice can be heard. And it also means that anyone’s voice can be heard. So, we are just as likely to stumble upon drivel as we are on information gold. And what takes time and skill is separating the two into neat piles, one to be ruthlessly discarded, and the other cherished for how it enriches us. To be sure without the web we might not have had access to either, and it is the egalitarian nature of the internet that gives us such a variety of sources in our information diet.

Now, let’s look at medicine. Every day we hear about how much noise there is in the field, and this noise is difficult, if not impossible, to separate from the signal. Some signals are becoming much clearer, and they tell us that by being too egalitarian in medicine, we have likely been causing great harm. Take, for example, PSA and mammography screenings.

The drumbeat of harm associated with these highly non-specific tests and the resultant chase after false positive results, is getting deafening, and rightfully so. Every day we hear that researchers have uncovered a breakthrough mechanism or treatment, and we hear with increasing frequency that a treatment previously thought to be sacrosanct is a bunch of rubbish. What gets lost among all this noise is the possibility of a true breakthrough in disease management or treatment or cure.

Think how hard it is to separate general valuable content from bunk on the web. Now, think of the logs of increase in the levels of difficulty of this task in medicine, where difficult concepts are further shrouded in the opaque cloth of arcane and obfuscating terminology. In fact, it is so difficult, that the class previously designated as the interpreters of this information for the lay public, physicians, are unable to keep up.

Continue reading…