By HANS DUVEFELT
This may come as a surprise for people with business degrees:
Doctors don’t really care when a test was ordered. We care about our patient’s chest X-ray or potassium level the very moment the test was performed. We also don’t care (unless we are doing a forensic review of treatment delays) when an outside piece of information was scanned into the chart. We want to know on which day the potassium was low: Before or after we started the potassium replacement, for example.
In a patient’s medical record, we have a fundamental need to know in what order things happened. We don’t prefer to see all office visits in one file, all prescriptions in another and all phone calls in a third. But that seems to be how people with a bookkeeping mindset prefer to view the world. In some instances we might need that type of information, but under normal clinical circumstances the order in which things happened is the way our brains approach diagnostic dilemmas.
Yes, I have said all this before, but it deserves to be said again. Besides, only 125 people read what I wrote about this six weeks ago, while almost 10,000 people read my post about doxepin.
Patients’ lives are at stake and, in order to do our job, we need the right information at the right time, in the order we need it, even if the bookkeepers prefer it a different way.
By ANISH KOKA
A recent email that arrived in my in-box a few weeks ago from an academic hailed the latest “paradigm shift” in cardiology as it relates to the management of stable angina. (Stable angina refers to chronic,non-accelerating chest pain with a moderate level of exertion). The points made in the email were as follows (the order of the points made are preserved):
- The financial burden of stress testing was significant (11 billion dollars per annum in the USA!)
- For stable CAD, medical treatment is critical. We now have better medical treatments than all prior trials including ischemia. these include PCKS9 Inhibitor, SGLT2-i, GLP1 agonists Vascepa and others
- CTA coronaries is by far the most important single test for evaluation of these patients
- ” the paradigm of ischemia testing may have come to an end”
- For stable angina (not ACS!) in most cases, the decision on revascularization should be based only on symptoms alleviation (as no survival benefit).
The general public should find it interesting, and not a random coincidence that the first point immediately gets to the financial burden of stress testing in a communication that is supposed to assess the level of evidence for the management of coronary artery disease. Imagine a cardiologist enters your exam room to talk about the chest pain you get every time you run up a flight of steps, and starts off the conversation with how much the societal cost of stress tests are. The cost of care is certainly a relevant concern, especially if it’s to be borne directly by the patient, but it would seem that the decision of whether a therapy is effective or not should be divorced from how much some bean counter decides to price the therapy to generate a certain return on investment. As such, the discussion that follows will omit any consideration of cost when evaluating the new ‘paradigm shift’ in management of coronary disease that is apparently upon us.
This particular debate boils down to the relevance of diagnostic testing for coronary artery disease. The traditional approach to testing is a functional test that utilizes the uptake of radioactive isotope injected into a patient during stress and rest conditions to identify mismatches in blood flow in the two states to identify myocardial ischemia. The amount of ischemia can be quantified as percent of total myocardium, and has been well correlated with prognosis. Having lots of ischemia typically means a much shorter lifeline than having little or no ischemia. The accepted paradigm in Cardiology has been to use traditional stress testing to triage patients to ‘conservative’ medical therapy or an invasive approach to bypass or open arteries via stents or coronary bypass surgery.
By HANS DUVEFELT
Insurance is the wrong word for what we have here. Our private health insurance system’s prioritization of sometimes frivolous screenings but non-coverage for common illnesses and emergencies is a travesty and an insult to typical American middle class families.
State Medicaid insurance for the underemployed has minimal copays of just a few dollars for doctor visits and medications. From my vantage point as a physician, it is the best insurance a patient can have. They cover almost everything and it is clear to me how to apply for exceptions or follow their step care requirements. I cannot say that about most other insurers.
Most employed people have the kind of commercial health “insurance” that covers an annual physical and certain screening tests at no cost, but requires people to pay the first several thousand dollars of actual sick care expenses out of pocket. This is, in my opinion, insane. It causes delays and omissions in diagnosis and treatment.
A shining example of this bizarre arrangement is the screening colonoscopy. It is free as long as it is normal. If a patient has a polyp removed, which if unchecked could turn cancerous, future health care costs for treating colon cancer are eliminated. But the patient gets billed for the early cure.
By MIKE MAGEE
The patient/health-professional relationship is fundamentally grounded in science and trust, and involves the exchange of compassion, understanding and partnership. The Covid-19 pandemic has challenged this relationship by acutely increasing the nation’s burden of disease, creating new barriers to face-to-face contact, and injecting high levels of fear and misinformation.
Dr. Sean Conley, Trump’s White House physician, in his dodgy and evasive management of legitimate questions from the White House press corps regarding the President’s health, has made matters worse.
As this week’s report on an analysis of 38 million articles on the pandemic revealed, much of the misinformation our citizens have experienced can be traced to a single individual who lacks any health credentials – our own President Trump. Sarah Evanega, the director of the Cornell Alliance for Science and lead author of the report stated, “The biggest surprise was that the president of the United States was the single largest driver of misinformation around Covid. That’s concerning in that there are real-world dire health implications.”
The solution to that specific problem is only one month away – vote him out. But if Trump can be successfully sent packing, how prepared are our health professionals, in the face of these new and complex challenges? A President Biden health reform package will likely include expansion of health care teams, exponential growth of telemedicine, and increasing dependence on reliable information to advance personal health planning.
Today’s modern health professionals are tomorrow’s health journalists. What principles should guide them in their new and expanded role. As a guide, I offer the following:
By HANS DUVEFELT
Interviewing celebrities can make you a celebrity yourself, and it can make you very rich. So there’s got to be something to it or it would be a commodity. The world of media certainly recognizes the special skill it takes to get people to reveal their true selves.
At the other end of the spectrum of human communication lies our ability to explain and also our ability to influence. These three aspects of what we do—elicit, explain and influence—are far from trivial, and in my opinion quite fundamental aspects of practicing medicine.
Eliciting an accurate patient history or administering standardized depression, anxiety, domestic abuse, smoking and alcohol screenings are commoditized activities in today’s healthcare. There is little time allotted and these tasks are usually delegated to non-clinicians.
A complicated patient’s clinical history seldom lends itself to straightforward, structured EHR formats. It can be more like a novel, where seemingly unrelated subplots converge and suddenly make complete sense in a surprising last chapter.
By NELLY GANESAN, JOSH SEIDMAN, MORENIKE AYOVAUGHAN, and RINA BARDIN
With support from the Robert Wood Johnson Foundation, Avalere assesses opportunities to normalize cost-of-care conversations through measurement.
Cost continues to pose a barrier to accessing healthcare for millions of Americans. Research has shown that conversations addressing costs among patients, caregivers, and the clinical team can help build a more trusted relationship between patients and clinicians.
Avalere has partnered with Robert Wood Johnson Foundation (RWJF) since 2015 to work toward normalizing cost-of-care (CoC) conversations in clinical settings, including identifying barriers and facilitators to engaging in conversations about cost. CoC conversations can be defined as discussions that address any costs patients and families might face, from out-of-pocket (OOP) to non-medical costs (e.g., transportation, childcare, lost wages). To that end, Avalere collaborated with the National Patient Advocate Foundation to explore the feasibility of patient-centered measure concepts to support quality improvement, increase satisfaction, and improve outcomes. This issue brief highlights the challenges associated with measurement in this space alongside alternative solutions to encourage CoC conversations in practice.
By CHADI NABHAN, MD, MBA, FACP
“The goal for me and for my clinical and research colleagues is to put ourselves out of a job as quickly as possible”. This is how Mikkael Sekeres ends his book “When Blood Breaks Down” based on true stories of patients with leukemia. I share Mikkael’s sentiments and have always stated that I’d be happy if I am out of a job caring for patients with cancer. To his and my disappointment, this wish is unlikely to ever come true, especially when dealing with leukemia.
With almost 15 years of experience, Sekeres possesses a wealth of knowledge and patient stories making him the ultimate storyteller taking us along an emotional journey that spanned hospital rooms, outpatient clinics, and even his car. We get to know Mikkael the person and the doctor and immediately recognize how difficult it is to separate these two from each other. With hundreds of patients he has cared for, Mikkael could choose which stories to share. He decides on 3 patients, each with a unique type of leukemia and a set of circumstances that makes their story distinct. While I don’t know for certain, his selection likely reflected his ultimate goal of writing this book. It was about sharing life lessons he had learned from his patients–lessons that we could similarly learn—but it was also about giving us a glimpse of history in medicine and the progress that has been made in treating leukemia.
We get to know the three main characters of the book very well. David is an older man with acute myeloid leukemia (AML), Joan is surgical nurse who suddenly finds herself diagnosed with acute promyelocytic leukemia (APL), and Mrs Badway is a pregnant woman who was in her 2nd trimester when she was diagnosed with chronic myeloid leukemia (CML). While learning about their illnesses and family dynamics, Sekeres educates us about the various types of leukemia and enlightens his readers about so much history that I found fascinating. I did not know that the Jamshidi needle that I have used on so many patients to aspirate their bone marrows was invented by an Iranian scientist. Maybe I should have known, but I didn’t, that FISH was developed at Yale in 1980 and the first description of leukemia has been attributed to a French surgical anatomist, Dr. Alfred Velpeau in 1827. Somehow, I always thought that Janet Rowley discovered the Philadelphia chromosome, but Sekeres corrects me when he pictured Peter Nowell and David Hungerford who discovered that chromosome in 1961. As a reader, you might be more drawn to the actual patient stories, but the geek in me enjoyed the history lessons, especially the ones I was unaware of. Sekeres inserts these pearls effortlessly and with perfect timing. He does that so seamlessly and naturally that you learn without realizing you are being taught.
By AMY E. KRAMBECK, MD
With the exceptions of pediatrics and obstetrics/gynecology, women make up fewer than half of all medical specialists. Representation is lowest in orthopedics (8%), followed by my own specialty, urology (12%). I can testify that the numbers are changing in urology – women are up from just 8% in 2015, and the breakdown in our residency program here at Indiana University is now about 20% of the 5-year program.
One reason for the increase is likely the growth of women in medicine – 60% of doctors under 35 are women, as are more than half of medical school enrollees. I also credit a generational shift in attitudes. The female residents I work with do not anticipate hostility from men in the profession and they expect male patients to give them a fair shake. They may be right – their male contemporaries are more egalitarian than mine – but challenges still exist in our field.
Urologists see both men and women, but the majority of patients are male. Urology focuses on many conditions that only affect men such as enlarged prostate, prostate cancer, and penile cancer. Furthermore, stone disease is more common in men, as are many urologic cancers such as bladder cancer and kidney cancer. So the greatest challenge for young women in urology is to gain acceptance among older men who require examination of their genital region and often need surgery. I’m hopeful that women entering urology today can meet that challenge, largely because we have already made significant progress. For the barriers we still face, leading urologists have blazed a clear path to follow with these three guideposts.
By ANISH KOKA, MD
Something didn’t seem right to epidemiologist Eric Weinhandl when he glanced at an article published in the venerated Journal of the American Medical Association (JAMA) on a crisp fall evening in Minnesota. Eric is a smart guy – a native Minnesotan and a math major who fell in love with clinical quantitative database-driven research because he happened to work with a nephrologist early in his training. After finishing his doctorate in epidemiology, he cut his teeth working with the Chronic Disease Research Group, a division of the Hennepin Healthcare Research Institute that has held The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) contract for the United States Renal Data System Coordinating Center. The research group Eric worked for from 2004-2015 essentially organized the data generated from almost every dialysis patient in the United States. He didn’t just work with the data as an end-user, he helped maintain the largest, and most important database on chronic kidney disease in the United States.
For all these reasons this particular study published in JAMA that sought to examine the association between dialysis facility ownership and access to kidney transplantation piqued Eric’s interest. The provocative hypothesis is that for-profit dialysis centers are financially motivated to keep patients hooked to dialysis machines rather than refer them for kidney transplantation. A number of observational trials have tracked better outcomes in not-for-profit settings, so the theory wasn’t implausible, but mulling over the results more carefully, Eric noticed how large the effect sizes reported in the paper were. Specifically, the hazard ratios for for-profit vs. non-profit were 0.36 for being put on a waiting list, 0.5 for receiving a living donor kidney transplant, 0.44 for receiving a deceased donor kidney transplant. This roughly translates to patients being one-half to one-third as likely to get referred for and ultimately receiving a transplant. These are incredible numbers when you consider it can be major news when a study reports a hazard ratio of 0.9. Part of the reason one doesn’t usually see hazard ratios that are this large is because that signals an effect size that’s so obvious to the naked eye that it doesn’t require a trial. There’s a reason there are no trials on the utility of cauterizing an artery to stop bleeding during surgery.
But it really wasn’t the hazard ratios that first struck his eye. What stuck out were the reported event rates in the study. 1.9 million incident end-stage kidney disease patients in 17 years made sense. The exclusion of 90,000 patients who were wait-listed or received a kidney transplant before ever getting on dialysis, and 250,000 patients for not having any dialysis facility information left ~1.5 million patients for the primary analysis. The original paper listed 121,000 first wait-list events, 23,000 living donor transplants and ~50,000 deceased donor transplants. But the United Network for Organ Sharing (UNOS), an organization that manages the US organ transplantation system, reported 280,000 transplants during the same period.
The paper somehow was missing almost 210,000 transplants.
By MIKE MAGEE, MD
As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today.
Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.
Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:
my own perspective, I have no reservations about accepting any, or all of the
foregoing articulations of various qualities, attitudes, and activities of the
physician as legitimate representations of important attributes for the
trustworthy professional. In fact, I find it difficult to choose one list over
others, since they each in turn seem to refer largely to the same general set
of admirable qualities. While we in medicine might see these as our lists of
the desirable attributes of professionalism in the physician, as the father of
an Eagle Scout I know that Boy Scout leaders use a very similar list to
describe the important qualities of scouts: ‘A Scout is trustworthy, loyal,
helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean,
reverent (respecting everyone’s beliefs).’ I make this observation not to
descend into parody, but to make a point. These various descriptions are so
similar because when we examine the field of medicine as a profession, a field
of work in which the workers must be implicitly trustworthy, we end by
realizing and asserting that they must pursue their work as a virtuous
activity, a moral undertaking.”