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Advances In Cancer 2012

The 30,000 member American Society of Clinical Oncology is the world’s leading group of cancer physicians. ASCO is dedicated to curing cancer, supporting research, quality care, reducing treatment disparities and a heightened national focus on value. This month they released their annual Report on Progress Against Cancer, which highlights research, drug development and cancer care innovations.  This hundred-page document is important reading for anyone who wants to be up-to-date regarding cancer care.

Cancer related deaths in the United States are dropping, but still totaled 577,000 in 2012.  While world cancer research funding is rising, in the USA it continues to decrease, with the purchasing power of the largest funding source, the National Cancer Institute, having fallen 20% in the last decade, and a further 8% cut slated for January 1, 2013.   Development is dependent on government and private funding, as well as the willingness of more than 25,000 patients a year who volunteer to be involved in cancer trials.  All these critical supports are threatened. The Federal Clinical Trials Cooperative of the National Cancer Institute (FCLC, NCI) supports research at 3100 institutions in the USA.

The report discusses the many types of cancer which continue to be naturally resistant to cancer treatment, particularly chemotherapy.  In some cases, drugs do not penetrate a part of the body, such as the brain, in other cases even when they reach the tumor, they are not effective.  In such cancers the genetic code of the cancer cells has mutated (changed) such that the particular drug does not kill the cancer.  In 2012, there was increased interest in attacking each cancer cell at multiple targets either by using a single drug, which attacks in several different ways, or multiple drugs at the same time.  This concept improved cancer killing in GIST, colon cancer, certain lymphomas (ALCL) and medullary thyroid cancer.  In addition, unique targeted compounds, such as “tyrosine kinase inhibitors,” show increasing benefit in leukemia, sarcoma and breast cancer.

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Through a Scanner Darkly: Three Health Care Trends for 2013

As we anticipate a new year characterized by unprecedented interest in healthcare innovation, pay particular attention to the following three emerging tensions in the space.

Tension 1: Preventive Health vs Excessive Medicalization

A core tenet of medicine is that it’s better to prevent a disease (or at least catch it early) than to treat it after it has firmly taken hold.   This is the rationale for both our interest in screening exams (such as mammography) as well as the focus on risk factor reduction (e.g. treating high blood pressure and high cholesterol to prevent heart attacks).

The problem, however, is that intervention itself carries a risk, which is sometimes well-characterized (e.g. in the case of a low-dose aspirin for some patients with a history of heart disease) but more often incompletely understood.

As both Eric Topol and Nassim Taleb have argued, there’s a powerful tendency to underestimate the risk associated with interventions.  Topol, for example, has highlighted the potential risk of using statins to treat patients who have never had heart disease (i.e. primary prevention), a danger he worries may exceed the “relatively small benefit that can be derived.”  (Other cardiologists disagree – see this piece by colleague Matt Herper).

In his new book Antifragile, Taleb focuses extensively on iatrogenics, arguing “we should not take risks with near-healthy people” though he adds “we should take a lot, a lot more, with those deemed in danger.”

Both Topol and Taleb are right that we tend to underestimate iatrogenicity in general, and often fail to factor in the small but real possibility of potential harm.

At the same time, I also worry about external experts deciding categorically what sort of risk is or isn’t “worth it” for an individual patient – a particular problem in oncology, where it now seems  fashionable to declare the possibility of a few more months of life a marginal or insignificant benefit.

Even less dramatically, a treatment benefit that some might view as trivial (for hemorrhoids, say) might be life-altering for others.  For these sufferers, a theoretical risk that some (like Taleb) find prohibitive might be worth the likelihood of symptom relief.  Ideally, this decision would ultimately belong to patients, not experts asserting to act on patients’ behalf.

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Is In Car Health Monitoring the Answer? Maybe? Maybe Not So Much?

Patient monitoring outside the hospital has been a hot topic (and also a not so hot topic) for the past 15 years.

Starting back in the late 1990s with companies like Health Hero Network, a company whose products for patient home monitoring are still in use today, company after company has sought to bring a successful product to market. The holy grail: finding an easy, non-intrusive, and continuously reliable way to predict patients’ potentially serious medical problems when it is early enough to do something about them and prevent an acute and expensive episode of illness.  Some of the newer companies are focused more on the wellness and tracking side of the equation, such as helping individuals see progress from an exercise or other preventive/health-inducing regimen.

So far this whole area has been a very tough nut for businesses to crack in the US in particular.  While some studies have shown great positive effect, others have not.  Insurance payment for these programs has been spotty at best and non-existent at worst; most of the current vendors are stuck in pilot hell without significant long term and widespread commitments from payers.  There is a belief, veracity unknown as yet, that the proliferation of risk-based entities such as Accountable Care Organizations will change this and lead to broad adoption of ambulatory patient monitoring tools, angels will sing and a large number of hospitalizations and rehospitalizations will be avoided.  That may be true, but remains to be seen.

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(Not) Saving the Best For Last

A clever little study was published last month in the Archives of Internal Medicine, and it – plus the fact that I’ve just started a stint as ward attending – prompted me to think about the importance of managing a set of tasks in the hospital. In my quarter-century of mentoring residents and faculty, I can’t think of an area in which the gulf between what people should do and what they actually do is larger, nor one in which improving performance yields more tangible rewards.

In this blog, I’ll begin by reviewing the Archives study and then consider its lessons for time management, particularly on the wards. In my next post, I’ll describe – just in time for New Year’s resolutions – a little technique I’ve developed that has helped me and others complete tasks that feel overwhelmingly large.

In the Archives paper, a research team led by informatician Michael Cohen of the University of Michigan set out to tackle the “portfolio effect”: how to allocate scarce time when discussing multiple patients. Cohen’s team videotaped 23 end-of-week resident sign-outs of ICU patients; on average, 11 patients were signed out per session, and each session lasted about 27 minutes. The patients were reviewed in bed order, not based on severity of illness or anything less random than where they happened to be lying in the ICU. (In my experience, this location-based sequencing is the most common method of organizing sign-out; going in alphabetical order of patients’ last names is a close second.)

Try to guess which patients were discussed at most length by the residents. The sickest? The oldest? The youngest? Those with the most complex social issues? Patients who were potentially eligible for ICU discharge that day?

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Making Sense of the Electronic Health Record

At 5am, Mr. A rolls onto the medicine floor: the fifth and final new patient to be admitted that night. The 70-year-old is well-known to our institution from his near-monthly hospitalizations and his primary care doctor, cardiologist, podiatrist, ophthalmologist, and both of his endocrinologists all work in-house. Unfortunately, for the intern admitting him (and for Mr. A), this translates into a few hours-worth of prior blood test results, MRI reports, visit notes, and discharge summaries to peruse. Where to begin? How to find the key details buried in this hoard of information?

Electronic health records (EHRs) have brought to health care both a much-needed modernity and an emerging challenge: how do doctors manage the rapidly growing quantities of health records that we are responsible for reviewing and that (theoretically) help us take better care of our patients, so that we can extract critical information while spending more time with patients and less in front of a computer?
There is little question that electronic records trump the tree-killing alternative (eg. that Mark Twain autobiography-sized pile of faxed paper, one line of doctor-scrawl per page, documenting a patient’s stay at an outside facility). But even electronic records can become unwieldy in the form now used in most hospitals, including Mass General: clinical data organized by the date a note was written or a blood test was drawn. 

Sorting through such files as quickly and effectively as possible is a skill that we must pick up early in residency. But what if a computer program could make this easier and more foolproof by pulling out the information we needed when we needed it? The technical term for this is “clinical summarization.” It’s a still rare feature that is gaining traction.  Continue reading…

The Empowered Patient

When you or a loved one enters a hospital, it is easy to feel powerless. The hospital has its own protocols and procedures. It is a “system” and now you find yourself part of that system.

The people around you want to help, but they are busy—extraordinarily busy. Nurses are multi-tasking. Residents are doing their best to learn on the job. Doctors are trying to supervise residents, care for patients, follow up on lab results, enter notes in patients’ medical records and consult with a dozen other doctors.

Whether you are the patient or a patient advocate trying to help a loved one through the process, you are likely to feel intimated—and scared.

Hospitals can be dangerous places, in part because doctors and  nurses are fallible human beings, but largely because the “systems” in our hospitals just aren’t very efficient.  In the vast majority of this nation’s  hospitals, a hectic workplace undermines the productivity of  nurses and doctors who dearly want to provide coordinated patient-centered care.

At this point, many hospitals understand  that they must streamline and redesign how care is delivered and how information is shared so that doctors and nurses can work together as teams. But this will take time. In the meantime, patients and their advocates can help improve patient safety.

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The Pain Index

A recent report by the New York Times contained an excellent graphic showing the current percentage of uninsured people in each state.  The range is from a high of 24.6% in Texas to a low of 4.4% in Massachusetts.I have combined this rate with the most recently reported CDC rate of obesity in each state to create what I call The Pain Index.  It is a simple sum of the two numbers. 

The theory behind the total is that obesity is a rough guide for the level of unhealthiness in the population.  My hypothesis is that, when insurance is made available to people, they will use it, roughly in proportion to the degree they are unhealthy.

Yes, I know this is a crude metric, but I think it will be a relatively good predictor of the rate of increase in health care costs in each state over the coming years.  This will show up in the insurance premium rates offered in the health care exchanges and will also affect the need for state appropriations to pay for newly eligible Medicaid subscribers.

States with a Pain Index in the top decile are: Texas, South Carolina, Louisiana, Mississippi, and Arkansas.  Others with scores over 45 are Nevada, Florida, New Mexico, Georgia, Alaska, Oklahoma, North Carolina, Kentucky, Alabama, and West Virginia.

My advice to policy-makers:  Get ready!  My advice to health care CEOs:  This would be a really good time to focus on quality, safety, and front-line driven process improvement as the most effective way to reduce your costs and improve efficiency.

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Questions and Answers

Things have been crazy.  It’s much, much more difficult to build a new practice than I expected.  I opened up sign-up for my patients, getting less of a response than expected.  This, along with some questions from prospective patients has made it clear that there is still confusion on the part of potential patients.  So here is a Q and A I sent as a newsletter (and will use when marketing the practice).

About My New Practice

Q. Why did I do this?

A.  I get to be a doctor again (perhaps for the first time).  I got tired of giving patients care that wasn’t as good as it could be.  I got tired of working for a system that pays more for bad care than for good.  I got tired of forcing patients to come in for care I could’ve given over the phone.  I got tired of giving time that should be for my patients to following arduous regulations.  I got tired of medical records not meant for actual patient care, but instead for compliance with ridiculous government rules.  Making this change gives me the one thing our system doesn’t want to pay for: time devoted for the good of my patients.

Q. How can I afford to do this?

A. I have greatly decreased my overhead by not accepting insurance and keeping my charges simple.  My goal is to have 1000 patients paying the monthly fee, which will limit the number of staff I need to hire.

Q. When will it open?

A.  My office will open in January, 2013, but the exact date is still not set.  I had initially hoped to be already seeing patients, but things always are harder than they seem.

Q.  What makes this better for patients?

A.  The main advantage is that I am finally able to give them the care they deserve: care that is not hurried, not distracted by the ridiculous complexity of the health care system, and not driven by the need to see people in person to give care.  This means:

  1. I don’t ever have to “force” people to come to the office to answer questions.  This means that I will let people stay at home (or work) for most of the care for which I would have required an office visit in the past.
  2. I will be able to give time people deserve to really handle their problems
  3. I won’t have to stay busy to pay the bills, so I can take care of problems when they happen (or when they are still small), rather than having to make people wait to get answers
  4. Patients won’t get the run-around.  They will get answers.
  5. I won’t wait for patients to contact me to give them care.  I will regularly review their records to make sure care is up to date.
  6. I will help my patients get good care from the rest of the system.  Avoiding hospitalizations, emergency room visits, unnecessary tests, and unnecessary drugs takes time; I will have the time to do this for my patients.  This should more than make up for my monthly fee.

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Can We Stop Dementia Before It Starts?

Few diseases invoke more fear in patients and families than dementia (e.g., Alzheimer’s Disease (AD), progressive multiple sclerosis, Pick’s Disease). Surveys have shown the fear of dementia—especially AD—far outweighs concerns of a diagnosis of cancer, stroke, or cardiovascular disease.

Perhaps this fear arises from two concerns: (1) dementia robs us of what makes us human—memory, reasoning, emotions, language—and (2) in most cases there are no effective treatments to cure or palliate the disease. While diagnostics for certain forms of dementia are progressing—allowing us to sort out the reversible causes of dementia, such as hydrocephalus, electrolyte or blood sugar imbalances, brain tumors, and brain injuries—once the diagnosis of AD or Pick’s disease is made, there is little we can do aside from manage the comfort and safety of the patient and family.

What if we could prevent or delay dementia?

In the mid-1960s, the incidence of heart attacks and stroke were increasing at an alarming rate. Great strides were made in treating existing cardiovascular disease, followed by programs at preventing the disease in the first place. These prevention methods included exercise, diet, and the tracking of key incidence indicators such as blood pressure, body mass index, and cholesterol levels to maintain a quantifiable physical health.

Could we use similar prevention methods for preventing or delaying dementia?

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Are In Vitro Fertilization (IVF) Clinics Scamming Customers?

Somewhere near where you live, a couple will discover this week that they are infertile and that if they want biological children of their own, they are going to need in vitro fertilization (or IVF).  According to treatment protocol, the woman will need to take powerful medicines to ramp up her production of fertilizable eggs.  One monthly cycle of this treatment will run around $12,000.  But most couples require more than one cycle to achieve their goal of carrying a child to term.  In other words, this couple could easily be looking at a bill exceeding $30,000 or $40,000.

And did I mention that this money could all come out of their own pockets?

Because not all insurance companies pay for in vitro fertilization.

No worry though.  Their infertility physician informs them about a company he has worked with that specializes in infertility loans.  He even offers to have his office staff help the couple fill out the necessary paperwork.  Thanks to this assistance, the couple secures the loan and, with luck, will soon be rewarded with a healthy baby.

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