Author Archives

Simon Nath

Precision Medicine is Taking Too Long and Here’s Why

Feb 11, 2016• 1

By DAN HOUSMAN

Screen Shot 2016-02-11 at 10.07.58 AM We have been talking about Precision Medicine for a long time now but so far we are still in the infancy of using genetics to impact medical decision making. The human genome was sequenced in 2003,with the promise of rapid medical advances and genetically tailored treatments. However, development and adoption of these treatments has been slow. Today with the advent of large cohorts, and in particular, the construction of the US Government’s Precision Medicine Cohort,[1] conditions are being set up for precision medicine to flourish. In the PMI infographic,it states three reasons for ‘Why now?’ – sequencing of the human genome, improved technologies for biomedical analysis, and new tools for using large data sets. While I agree this is progress, I believe there area few fundamental other areas to be tackled in order to really get to the promise of precision medicine.

The concept of protocols is designed for mass production not mass personalization

Medicine is practiced using protocols and documented in EHRs. When written down they can look like a cook book or a choose-your-own-adventure story book. The intent is to codify medical knowledge into a guide that can be consistently used by all physicians to obtain the ideal outcome. But as a result of strict adherence to medical practice standards, they inherently choose paths that are well defined based on the assumption that most people are similar in their response to treatments. So over time the protocol is enhanced to suggest which decision is the right one to make with a given patient and a protocol will more often than not be ‘anti-precision,’ just in the same way that a factory is designed to make one size of jeans at a time rather than make a custom set of jeans for each customer visiting the store.

Shining the Light on Cancer Surgery Volume

Feb 10, 2016

By JULIANNE MORATH, MD and DAVID PERROTT, MD

flying cadeucii New data just released on cancer surgery volume in California hospitals advance an important and complex discussion about how the frequency with which a cancer surgery is performed at a hospital might influence patient, care team and hospital decisions. An effort funded by the California HealthCare Foundation has recently made these data available for the first time for 341 California hospitals on www.CalQualityCare.org. Having these data readily available opens the door to important inquiries the hospital community is investigating closely. Transparency about cancer surgery volume is, however, just one step toward better understanding and practice. More data and close deliberation are needed, and we must take caution to avoid premature conclusions with insufficient evidence.

Accompanying the release of these data is a new report, Safety in Numbers: Cancer Surgeries in California Hospitals,highlighting important findings about the frequency and location of surgeries for 11 types of cancer.The report reveals that many hospitals performed certain cancer surgeries only once or twice in 2014 and that many cancer patients were within 50 miles of another hospital performing their needed surgery with greater frequency. The report is spurring productive discussion. However,as it is descriptive of cancer surgery volume alone and does not capture patient outcome, it calls on the hospital community to gather more evidence to inform decision-making. As conveners and catalysts for hospital improvement, the California Hospital Association and the Hospital Quality Institute, along with other leaders, are capturing this opportunity to advance the research and dialogue on cancer surgery volume.

It’s Time to Talk about Cancer Surgery Volume

Feb 10, 2016• 2

By JENNIFER MALIN, MD

Twenty years ago as a newly trained oncologist, I faced the same challenge that many cancer patients and their families do as they try to figure out where to turn when my mother was diagnosed with ductal carcinoma in situ– or pre breast cancer. Her surgeon, who had come highly recommended by her family doctor,told her she needed to have a lymph node dissection, which can result in lifelong disability due to lymphedema or swelling of the arm. As an oncologist, I knew it was not recommended for ductal carcinoma in situ, but she resisted my suggestion to get a second opinion. Despite the fact that I—her daughter—am an oncologist, her first thought was, “I can’t go against what my family doctor told me to do.”

It is still not part of our general culture to question physicians and, in a sense, to discuss health care options. Many patients are shell shocked by a cancer diagnosis and don’t think beyond what they are immediately told to do or where they are told to go for treatment. Some highly motivated patients dig deeper to research their options for cancer treatment, but these motivated patients are still a minority.

Can the Exchanges Be Saved?

Feb 6, 2016• 3

By MICHAEL TURPIN

Michael Turpin 1 “The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.” —William Arthur Ward

Looking confidently past the skeletons of drowned state and federal healthcare experiments, America’s health insurance exchanges set sail in January 2014. Disregarding the rough seas ahead, healthcare reform pundits and legislators applauded the Affordable Care Act’s signature public expansion vehicle as an impenetrable solution for achieving affordable coverage and competition.

Less than two years later, the exchanges are taking on water.

In November, United Healthcare lowered earnings projections, a move driven primarily by its hesitancy to commit to enrolling new exchange members until risks are better understood. While other insurers were quick to reassure investors that the public exchange market remains a viable means for organic growth, a low-pressure system of doubt is already building over the nascent public exchanges.

Initial enrollment projections for 2016 are fewer than 10 million members—about half of the 20 million target estimated by the Congressional Budget Office. In their rush to expand coverage to the uninsured and under insured, many public officials and industry neophytes failed to consult with those who have firsthand experience with the difficulties of underwriting those who are obtaining insurance for the first time.

FAST FOCUS

Enrollment projections for 2016 are fewer than 10 million members—about half the Congressional Budget Office target of 20 million.
The rush to participate in public exchanges has attracted inexperienced players seeking a piece of a $300 billion premium opportunity.
Investors want desperately to believe healthcare is ripe for transformational disruption.

Biden’s Moon Shot and the 21st Century Cures Bill

Feb 6, 2016• 2

By STEVE FINDLAY

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Lawmakers in Washington are gearing up to pass major, far-reaching legislation on drug approval and cancer research. This is a good thing in the main but—no surprise here—Republicans and Democrats differ on approach and details, and things are already getting messy.

This makes the proposed legislation very risky. It could all implode in an election year, but momentum is building fast and both parties have something to gain by passage.

This blog is a primer on what’s happening. Future posts will track the legislation’s progress and delve into some of the issues at stake. Comments are invited.

The Secrets of Cancer Survivors

Feb 6, 2016• 5

By JAMES SALWITZ, MD

Disclaimer: I have never had cancer. Therefore, at the most basic level, I do not have the right to pontificate about dealing with the dread disease.

Rather, I have been the servant and support of those that struggle with cancer. I thought it might be of some assistance to share my observations from the other side of the bed rail. Perhaps, their secrets of survival may help you.

1. Cancer is a team sport; do not do this alone. Never show up to an important appointment by yourself. You are dealing with a physical impairment, as well as a complex mental challenge, at the same time that you are frightened and do not feel well. Have someone with you to listen, ask, take notes and simply carry your things. This is true not only during treatment, but at home. Accept support. Build a team. Work together to fight this awful thing.

2. In the same way, whether you like it or not, a family goes through this together. Those that love you, also “get cancer.” Working together helps everyone deal with the affects of the disease. You are not a burden. You reap what you sow.

3. Nonetheless, it is also important to get time for yourself. You need grounding time; quiet moments to heal. Take a deep breath; rebuild. If your family does not understand the importance of “me time,” show them this note.

4. Be on time for your appointments, tests and treatments. This is my own hang-up, but being on time is part of being organized and I have noted that the patients that are punctual are organized and those that are organized do better.

5. Be whiney. Really, complain a lot. Tell your doctors what is happening. Take notes. Email. Call. Will the doctor give you his cell number? Do not ignore a fever for five days, crawl into the doctor’s office, and say, “By the way, I feel terrible.” That will result in the doctor saying, “By the way, time to go to the hospital.” This is why women make better patients then men; malignant macho.

Physician Burnout is an Epidemic

Feb 5, 2016• 4

By ANEES CHAGPAR, MD

There is a disease sweeping the nation that has significant consequences for every person living in this country, even if they never contract it directly. And despite its lethality, there is precious little being done about it. It’s called physician burnout, and it affects all of us.

Doctors, on average, spend at least eight years in college, followed by years of postgraduate training during which time they work 80 hours a week. They graduate with a mountain of debt, face the constant fear of malpractice litigation, and are burdened by incessant demands to see more patients in less time with more administrative paperwork. On top of which, there’s compassion fatigue – helping the sick, the injured and the dying is rewarding no doubt, but often emotionally draining. All of this leads to physician burnout.

More than any other profession, doctors face burnout, and the rates have been increasing. A recent study by researchers at the Mayo Clinic found that the number of physicians suffering from burnout is 54%, up from 45% in 2011. And physicians are more than twice as likely to commit suicide than non-physicians; every year, 400 doctors in this country take their own lives.

Why should you care? Because the emotional health of doctors has a direct effect on the broader public. There are a plethora of stories of physicians who describe the chilling consequences of their depression. One surgeon wrote in a recent blog, “my depression…was exacerbated by work. I clearly wasn’t performing to the best of my abilities, and my patient complications and complaints were increasing. A patient died from a post-operative bleed. Would I have managed it better if I wasn’t suffering myself? (When I spoke to the patient’s wife, as he lay dying 20 feet away, she asked me if I was OK.)” Burnout causes a lack of clarity in thinking leading to medical mistakes. “Given the extensive evidence that burnout among physicians has effects on quality of care, patient satisfaction, turnover, and patient safety, these findings have important implications for society at large,” researchers from Mayo Clinic told Forbes.

The Search for the Elusive Elixir of Life

Feb 4, 2016• 17

By TOM EMERICK

flying cadeucii Here’s the executive summary: Most disease and health spending is age-related. As we age we get infirmities ranging from dementia to cancer to vascular disease. Nothing can prevent aging. Period. For millennia mankind has been been on a futile search to prevent aging.

Search for the Elusive Elixir of Life

For 3500 or more years mankind has been searching for the mythological Elixir of Life, the fountain of youth, the philosophers stone, pool of nectar, etc, that will defeat aging and extend life, if not achieve immortality.

According to Wiki, “The elixir of life, also known as the elixir of immortality and sometimes equated with the philosopher’s stone, is a mythical potion that, when drunk from a certain cup at a certain time, supposedly grants the drinker eternal life and/or eternal youth.”

All around the globe from 400 BCE alchemists, from India to China to Europe, were seeking the elixir of life. Many thought gold was an essential ingredient of such an elixir.

The Fountain of Youth, also known as the water of life, was part of the search for the elixir of life. That search was in full throttle during the crusades, and was carried to the New World by Spanish explorers, the most famous of whom was Ponce De Leon in the 1500’s. Even the Mayans had legends about waters of eternal youth.

Gawande, Frankl, and Why “Less Is More” Is More of the Same

Feb 3, 2016• 4

By MICHEL ACCAD, MD

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My last post was prompted by a reader’s comment where Victor Frankl’s Man’s Search for Meaning and Atul Gawande’s Being Mortal were juxtaposed. Since receiving that message, I have had occasion to notice that others also associate these two books.

For example, both are mentioned positively in this moving article by Dr. Clare Luz about a friend’s suicide, and in these tweets from Dr. Paddy Barrett’s podcast program:

Friends and patients of mine have likewise mentioned these two works to me, expressing praise and testifying to the deep impact the books have had on them.

I suspect that many readers of this blog will at least be familiar with these two books. If not, summaries are here (Frankl) and here (Gawande).

Short-selling Private Practice

Feb 3, 2016• 1

By KAREN SIBERT, MD

Today is a remarkable day for me. I’m officially leaving private practice after almost 18 years, to return to academic medicine with a faculty position in a highly regarded California department of anesthesiology.

Why would I do that?

There are many positive reasons. I believe in the teaching mission of academic medicine: to train the anesthesiologists of the future, and the scientists who will advance medical care. I enjoy teaching. The years I’ve spent at the head of the operating room table, anesthetizing patients every day, have given me a great deal of hands-on experience (and at least some wisdom) that I’m happy to pass along to the next generation.

But the other, more pragmatic reason is this. I’ve lost confidence in the ability of private-practice anesthesiology in California to survive in its prevalent form — physician-only, personally provided anesthesiology care.

MD-only: A viable model?

California is an outlier among all other states in its ratio of physicians to non-physicians in the practice of clinical anesthesia. Nationally, there are slightly more non-physicians — including nurse anesthetists (about 47,000) and anesthesiologist assistants (about 1,700) — than physician anesthesiologists (about 46,000) in the workforce, according to 2015 National Provider Identifier (NPI) data.