Author Archives

John Irvine

Is Marital Status in a Febrile 5-year-old Child Important?

Jan 9, 2018• 3

By NIRAN AL-AGBA, MD

My pediatric practice is one which harkens back to days long ago when physicians knew their patients and pertinent medical histories by heart. My 81-year-old father and I were in practice together for the past 16 years; he still used the very sophisticated “hunt and peck” to compose emails. The task of transitioning to an electronic record system seemed insurmountable, so we remain on paper. Our medical record system has not changed in almost five decades. I would not have it any other way.

This past spring, he walked into my office shaking his head in disbelief after thumbing through a stack of faxes. “Can you believe this 16-page emergency room note has no helpful information about the patient?”

This was not a shock to me. The future of medicine will include robots who are paid to collect reams of useless data to provide nothing in the way of health or care. Regardless, the government and third-party payors will extoll upon the virtues of their inept system as life expectancy falls.

Fifty years ago, there was a close relationship between a physician and their patient grounded in years of familiarity. Physicians took a history, performed a physical exam, and developed an assessment and plan. Diagnosis in a child with fever would be descriptive, like Bacterial Infection, Otitis Media, Fever of Unknown Cause, or Viral Illness. Parents were advised to provide supportive care, involving clear liquids, fever medication, and follow up precautions if the child worsened.

What Is An Abnormal Test Result?

Jan 9, 2018• 6

By ROBERT MCNUTT, MD

Most teachers of evidence-based-medicine talk about tests as “positive, or negative”. A positive test is one in which the result of the test is abnormal; a negative test is one in which the test’s result is normal. A problem with this way of teaching about the value of test results is that often physicians and patients think there are only two possible test results, normal or not. However, test results are never just, “normal or abnormal”; test results may take on many values, not just two. ,

Researchers distinguish normal test results by performing the test in people who are well. For example, 100s of normal people will have blood tests done and the test results will vary over a narrow range. A serum potassium test result may be as low as 3.0 and as high as 4.0 in normal people, for example. An abnormal test result for potassium, then, is one whose value is greater than the highest in the range of values in normal people. But, the greater the potassium level, the more the diagnostic and treatment decisions may vary. In tesing, the magnitude of the result matters.

A key concept in testing is that the value of any test result may vary. The more abnormal it is, the more information it “contains” in terms of making a diagnosis. This may seem self evident, but failing to consider the absolute value of a test result is a common cause of missing the correct diagnosis in my experience.Continue reading…

A New Non-Partisan Panel to Monitor the President’s Health

Jan 7, 2018• 4

By ARTHUR CAPLAN PhD & JONATHAN MORENO PhD

The White House has announced that President Trump has scheduled an annual physical exam for Jan. 12. The President will go to Walter Reed National Military Medical Center in Bethesda, Md., the largest military hospital in the nation. White House press secretary Sarah Huckabee Sanders says Dr. Ronny Jackson, a rear admiral in the U.S. Navy who has served as physician to the President since 2013, “will give a readout of the exam after it’s completed.”

Some may have greeted this announcement with relief. Finally, concerns about the President’s slurred speech, overall mental health, crummy diet and obesity will be publicly addressed. Don’t get your hopes up.

A physical tends to be just that—an assessment of the physical not the mental. The evaluation of mental health in a standard physical is, to be polite, very cursory.

And while it is good that Trump at 71 will get a physical, he is under no obligation to reveal anything concerning that the exam turns up. When you are Commander-in-Chief and an Admiral reports on your exam, it is very clear that the Admiral had better be prudent about what gets said about the boss. Same goes for those on active duty at Walter Reed who perform the exam. Moreover, Trump has the same right to privacy that you or I do when we choose to get a physical or undergo any other medical procedure. It is up to him what he reveals to the rest of us.

The White House is well aware that they control what we will learn about the President’s health. And control the results they will.

No Surprise, Life Expectancy Declined Again

Jan 3, 2018• 12

By NIRAN AL-AGBA, MD

Newborns born in 29 other countries of the world have life expectancies exceeding 80 years; yet, an infant born in the US in 2016 is expected to live only 78.6 years according to recently released statistics. While death rates fell for 7 of the 10 biggest killers, such as cancer and heart disease, they climbed for the under-65 crowd. The irrefutable culprit is the unrelenting opioid epidemic.

Last year life expectancy declined for the first time since 1993. The last two-year decline was in 1962 and 1963, more than a half-century ago. I predicted (accurately) it would decline again this year unless there was a dramatic change in the primary care physician workforce. We are dying at a younger age today than two years ago– two months earlier to be exact. It might not sound monumental, but life expectancy is the king of noteworthy health statistics, making it quite significant in the grand scheme.

In the past, epidemics by definition were temporary; the narcotic epidemic will be anything but transient; there is no foreseeable end for the scourge of opioid addiction sweeping the nation. In my humble opinion, the solution to this dilemma is no different than it was last year, we must correct the primary care physician shortage. Time is of the essence. The last three-year decline occurred in 1912- 1914 as a result of the Spanish flu. Unfortunately, life expectancy will continue to decline until the nation makes comprehensive changes.

One in five Americans live in a primary care shortage area; the ratio of the population to primary care providers is greater than 2,000 to 1 (Bodenheimer & Pham, 2010), when it should be closer to 1,000 to 1. I am a third-generation primary care physician, with a unique historical perspective on how medical practice has changed since my grandfather made house calls back in 1940. My practice is currently located in a shortage area and the difference in volume compared to 16 years ago when I first hung a shingle, is extraordinary. Only 37% of doctors serve in primary care, yet 56% of the office visits are completed by that particular group of physicians (Health Resources and Services Administration, Bureau of Health Professions, 2008.) In my grandfathers’ time, primary care physicians made up 70-80% of the physician workforce.

The Death of Objectivity

Jan 2, 2018• 23

By MICHAEL TURPIN

For veterans of the healthcare industry, the current debate over the future of the Affordable Care Act – and proposed changes that would fundamentally alter Medicaid and individual market exchanges – is a frustrating battle of ideologies with the future of healthcare at risk. Our debate over who should be eligible for expanded coverage and how we reform reimbursement is often laced with self-preservation, which in our case means preserving an employer-sponsored system that is riddled with inequities, opacity, dubious middlemen and weak public and private sector fiduciary oversight. Those who provide, pay for and/or consume healthcare are drowning under rising per capita costs while many in the middle of these transactions grow fat.

As brokers, consultants and advisors, we have to face an inconvenient truth: we have presided over and benefited from a system in crisis. Not everyone believes our industry’s purpose is noble or necessary.

Health system stakeholders long to deal direct with employers. Many professional benefits managers hate being on the end of the latest pitch from their advisor to sell a project or broker to hawk a new product to increase commission income. In the digital age, there is a heavy bias in favor of disintermediation and the elimination of distribution costs that are often not easily rationalized.

How does one grade the contribution of a sentinel? How does a client know whether the advisor who is paid a commission or fee is acting out of self-interest or as a trusted change agent?

How one makes money is as important as how much one makes in certain industries. There are ethical implications to anyone who adds cost to a healthcare system fraught with waste, fraud and abuse. This expense translates into higher cost and erodes the ability for employers and public entities to finance care for those that are often most in need.

In the last two decades, ineffective regulatory and advisory oversight of the financial and healthcare industries has allowed abuses to take place in the form of mergers and protected opacity in pricing.

The Other Opioid Epidemic

Jan 2, 2018• 2

By HANS DUVEFELT, MD

“I made myself a hypodermic injection of a triple dose of morphia and sank down on the couch in my consulting-room….I told her I was all right, all I wanted was twenty-four hours’ sleep, she was not to disturb me unless the house was on fire.”
– Axel Munthe, MD, The Story of San Michele (1929)

When people in this country mention the opioid epidemic, most of the time it is in the context of addiction with its ensuing criminality and social deprivation, and the focus is on opioids’ medical complications like withdrawal, overdose and death.

But that is only one of the opioid epidemics we have. Far greater is the epidemic of largely compliant patients who take their modest three or four daily doses of opiates for pain that was originally described as physical, but which in many cases is at least as much psychological – not imagined, in fact often quite severe, but nevertheless without a physical explanation or available cure.

Stimulation of opioid mu-receptors in the central nervous system induces euphoria more reliably than it reduces pain. In fact low dose opiates have been shown to sometimes lower pain thresholds but at the same time allowing dissociation from the pain experience.

The Political Economy of Fentanyl

Jan 2, 2018• 4

By KAREN SIBERT, MD

Just say No to Fentanyl.

No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

What is fentanyl?

Fentanyl is an opioid pain-killer in the same class as morphine or Demerol, meaning that it acts on the same receptors in the brain to lessen the subjective experience of pain. It appeared on the market in 1960, and quickly gained wide use in anesthesia practice.

Fentanyl is potent and works fast, which makes it very effective in treating the intense stimulus of surgical pain, and its peak effect lasts only a short time. It’s also inexpensive, which makes it attractive in an era of cost containment in healthcare.

When I started my anesthesia residency, we assumed that since fentanyl’s analgesic and euphoric effects were so brief, short-term exposure to the drug wouldn’t increase a patient’s risk of long-term narcotic abuse. For the first few years, fentanyl was kept in unsecured medication carts in the operating rooms along with Benadryl, lidocaine, and other commonly used medications.

The Health Care System in 2018: Combat Zones to Watch

Dec 29, 2017• 2

By PAUL KECKLEY

Entering the home stretch on 2017, the stage is set for some classic duels next year: they’re about money and control and they’re playing out already across the industry. Here’s the five combat zones to watch:

Hospitals vs. insurers: This is the quintessential struggle between two conflicting roles in our system. Hospitals see themselves as the protector for a community’s delivery system, bearing risks for clinical programs, technologies and facilities that require capital to remain competitive. Insurers see themselves as the referee for health costs, calling balls and strikes on the necessity and cost-effectiveness of improvements providers deem essential. Each sees the other as complicit in healthcare waste and guard jealously their leverage: hospitals enjoy community support and physician relationships and insurers controls premiums. Around the country, the combat zones involve stand-offs involving reimbursement negotiations and narrow networks (i.e. Mission Health (Asheville NC) and Blue Cross of NC), coverage determinations by insurers that impair hospitals (i.e. Anthem’s decision to deny coverage for unnecessary emergency room use) and others.Continue reading…

What’s Wrong With American Doctors?

Dec 28, 2017• 10

By BRIANNA GRAFF

It is February of 2005, and my grandpa is lying in an Intensive Care Unit bed at Beth Israel Deaconess Medical Center in Boston, critically ill from a renal artery rupture that planted him face-first in his parlor. As a functioning alcoholic who has already been in the hospital for a day, he is beginning to shake periodically, a sign of his withdrawals.

Still, it will take another twelve hours and exasperations from both my mother and grandmother (both nurses themselves) before the physicians get him the Ativan he needs to combat this symptom, which is small potatoes compared to his emergent reason for admission.

While he would eventually make a full recovery, in those few hours my grandpa had tremors he was also the unintended victim of “tunnel vision” exhibited by many physicians: they see the most prominent problem and address it, often losing grasp of a holistic view of the patient and neglecting his humanity in their attempt to treat him. In short, they see the medical problem as opposed to the entire person.

Of course, this doesn’t mean that doctors are heartless: the number one reason doctors choose the profession is to help people, and the grueling work it takes to become an MD is clear evidence of their devotion to their career. So how did we end up here, with doctors overlooking the humanistic nature of their work?

Why An Individual Mandate Is Important and What States Can Do About It: Lessons from Massachusetts

Dec 27, 2017• 3

By ROSEMARIE DAY

The sweeping tax reform package recently signed into law will eliminate the Affordable Care Act’s (ACA’s) individual mandate in 2019, which is projected to reduce the number of people covered by health insurance by 4 million in 2019 and 13 million in 2027, while increasing premiums in the nongroup market by about 10% annually.1 For taxpayers seeking protection from high health care costs, this is a potentially catastrophic result.
Say what you like about the individual mandate, it is clearly an essential component of the ACA’s “three-legged stool” that – along with guaranteed issue and premium subsidies – has been effective in expanding health insurance coverage to millions.

Why is an individual mandate important?

Several studies show that, in a market that requires insurers to cover individuals with pre-existing conditions, an individual mandate helps ensure a healthy risk pool, which in turn helps to manage cost, affordability and sustainability. We learned this in Massachusetts, in the early days of implementing our version of health reform (which later became the model for the ACA). We had something close to a “natural experiment,” in which we launched a subsidized healthcare program before we implemented the individual mandate (we put the carrots out before we brought in the stick, in other words). Researchers were then able to study what happened to the risk pool, before and after the mandate.

As illustrated below, when the Massachusetts individual mandate went fully into effect in late 2007, there was a much larger increase in the number of healthy enrollees compared with enrollees with a chronic illness.2 What’s remarkable is that nothing else had changed in the program – the subsidy amounts were the same, as were all of the other enrollment requirements. But once people in Massachusetts understood they had to purchase insurance, the number of healthy enrollees jumped up.

Based on these results, and other relevant studies, the following projections have been made regarding the impact of eliminating the individual mandate: