I remember 7 South at the Children’s hospital very well. I remember the distinctive smell, the large rooms, the friendly nurses, and Shantel. For a brief period of time, Shantel and her little boy – a too skinny child named James – were there every time I was there with my little girl. 7 South was the GI floor – Shantel and I were there because our children had the same dastardly liver disease that, for the time being, was winning. And that was it. We had nothing else in common.
She grew up in North Philadelphia, not far from where I was finishing a residency program in Internal Medicine. She had three other children, was a single mother, and in the year that I spent shuttling to the hospital I never saw the father of her child. Shantel did not work, and relied almost exclusively on the welfare programs to make life work.
I was a medical resident, our family had a combined income north of $150,000/ year, and our health insurance was through my employer. My wife and I worked, which meant that we had the flexibility for one of us to stop working, and still maintain our benefits.Continue reading…
You may have heard that repealing and replacing Obamacare recently failed. The analysis of what went wrong comes from many corners. Andy Slavitt, former insurance executive and most recent director of CMS, writes that the ‘failure of Trumpcare can be seen as a rejection of policies that Americans judged would move the country backward.’ Apparently, the theory goes, moderate republicans, especially in states that expanded heavily and rely on Obamacare Medicaid expansion, were skittish of a repeal and replace plan that endangered the healthcare of millions of constituents. The conservative David Frum writes in the Atlantic that most Democrats and Republicans have accepted the concept of universal health care coverage – and that the idea of a repeal of the right to healthcare is sheer anathema. And if the Republicans were wavering, town halls filled with angry constituents were sure to provide an extra dollop of pressure.
The effort to get the messaging right is clearly important to many, but I find most of it functions as a smoke screen seeking to obscure the real battles being fought over your healthcare.
It is certainly true that Obamacare insures millions of Americans. But it is also true that having health insurance and having health care are two very different things. To be clear, the folks attempting to preserve the status quo want to preserve the ability to force all Americans to buy health insurance that costs hundreds of dollars per month. Put another way, the folks attempting to preserve the status quo want to force Americans to give a monthly fee to health insurance companies. Remember, these plans have deductibles so high that most of the cost of care delivered during the year in the form of labs, copays, and imaging studies falls on the hapless patient. The insurer, for the average healthy person, doesn’t pay a dime.
Arguably, the most consequential moment of the nascent Trump administration will take place later today when Congress Votes on the first iteration of the bill known as the American Health Care Act (AHCA). If the success or failure of the bill to this point is to be judged by its reception from policy thinkers on most sides of the political spectrum, it is already an unmitigated failure.
It should be worth noting, however, that healthcare in America is a massive business accounting for 3 trillion dollars in spending with powerful stakeholders. Any real attempt at reform is bound to be opposed by those who would naturally resist attempts to dam the river of dollars that flows to them. The resistance from these parties always comes in the form of entreaties to think about patients harmed by whatever change is trying to be made.
Figuring out which stakeholder actually has the patients best interests at heart is akin to playing a shell game. All the cups look the same and its entirely possible the marble is underneath none of the cups. As a physician, I am of course, another stakeholder with inherent bias but I would submit that practicing physicians, among all the players at the table, have their interests most aligned with the patients they must directly answer to every day.Continue reading…
This story is old, but the age of the story should not detract from the lessons of the story.
It was 1982, the place was Tsukuba, Ibaraki Prefecture, Japan. Workers at Fujisawa pharmaceuticals began testing fermented broths of Streptomyces species that had been retrieved from soil samples at the base of Mount Tsukuba. They were working to solve the remaining achilles heel of organ transplantation – effective suppression of the immune system that would prevent the body from attacking its new guest. It had quickly became apparent to the medical community that the key to long term survival of patients now lay in the development of effective, non-toxic immunosuppressive agents.
After two years of testing, isolate no. 9993, which later came to be named FK506, or Tacrolimus, showed promise in inhibiting lymphocyte reactions. First reports emerged in the literature in 1987, and were impressive. The agent appeared to suppress mixed lymphocyte culture at concentration 30 to 100 times lower than the gold standard at the time: cyclosporin. (1)
The father of organ transplant, Thomas Starzl was in Pittsburgh at the time, and quickly seized on the potential of this new agent. By 1990, he had used the drug successfully in patients who were rejecting their liver transplants on conventional cyclosporine based immunosuppression. The positive results of the ‘rescue’ trial prompted initiation of a randomized control trial in Pittsburgh that compared cyclosporine to FK506 from the time of transplant. At the time, the randomized control trial was in its relative infancy, and had not yet achieved the hallowed status it has today. This, of course, was changing rapidly. Physicians recognized the fallacy of epistemology sourced purely from intuition and tradition, and sought the shelter of certainty that randomized control trials (RCTs) promised with the random allocation of patients to treatment and control arms. The Pittsburgh team thus randomized 81 patient, 40 to cyclosporine – the conventional treatment – and 41 to FK506, the new kid on the block. Investigators studied patient mortality and survival of the transplanted organ at various time points. By convention, results were analyzed using statistical hypothesis testing – and to the lay person would seem to be underwhelming.
Eugene’s wife is on the phone. She has been taking care of Eugene for 41 years. I supposedly take care of his heart, weakened by two prior heart attacks. I say supposedly because his wife does all the heavy lifting. She makes sure he takes his medications when he should. She watches his weight every day and occasionally administers an extra dose of diuretic when his weight climbs more than a few pounds in a day. And perhaps most importantly, she calls me when Eugene’s in the hospital and things seem wrong to her. This is one of those phone calls. They were in the ER, Eugene hadn’t been responding to his diuretic as he normally does, and his breathing seemed more labored to her. The ER physician wanted to send them home – she was hoping I would weigh in. Not surprisingly, she was right, Eugene needed to come into the hospital. I used to be surprised when the ER wouldn’t call me for complex cardiac patient having an acute cardiac problem. Not any more.
There is a clear culture shift that is obvious to those who have spent any time in the ER over the past ten years. Low risk patients used to be managed and discharged from the ER, and higher risk patients were quickly admitted to the hospital for management by specialists. This used to be a source of tremendous friction with the ER in my younger years, as I would try to explain to ER physicians that every single chest pain in a patient with known coronary disease did not deserve admission. I seldom have this conversation with the ER anymore. What changed?
Brexit has been hailed as a turning point in the history of Western Democracy by a collection of liberal and conservative elites that decry the vote of a disenchanted and ignorant populace. The greatest threat to democracy in the modern age turn out to be the very same people that make up the democracy. We are told these are the same forces that propel Donald Trump forward. It is a convenient narrative that extinguishes any real debate on policy. If you support Brexit or Donald Trump you are an uninformed, xenophobic bigot. Yet here I am – an Indian immigrant, a physician, and a lifelong democrat to boot, who sees no other choice than Trump this election cycle.
I must confess that I have no emotional connection with Mr. Trump – his public demeanor, braggadocio, and above all, the coarseness of his manner when he engages opponents are not what are familiar or soothing to eye or ear. Yet, as a physician who has struggled through the last eight years of policies and regulations that have made my ability to take care of patients more and more difficult, Mr. Trump has taken on the form of an orange-tinged life preserver.
Recently, Anish Koka, MD, a Cardiologist from Pennsylvania, posted his anti-Accountable Care Organization (ACO) manifesto here on The Health Care Blog.  Koka argues that ACOs don’t work and are doomed to fail because they were designed by non-practicing physician policymakers and academics in ivory towers. He appears to be basing his judgment on a commercial ACO contract that only pays him $4 per month extra for care coordination and requires that he meet specific quality measures. He is also conflating his experience in a commercial ACO with Medicare ACOs, and interprets the initial results of one Medicare ACO program to mean that all ACOs are a failure. Finally, he relays an anecdote of caring for one of his patients, Mrs. K, a patient with chronic illness who doesn’t want to take her medication.
In his post, Dr. Koka calls out “well-meaning, hard-working folks that own a Harvard Crimson sweater…[whose] intent is to fundamentally change how health care is provided.” As luck would have it, I do own a Harvard Crimson sweater, and I’d like to respond.
I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.
It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.
Accountable care organizations (ACO’s) promise to save us. Dreamed up by Dartmouth’s Eliot Fisher in 2006, and signed into law as a part of the Patient Protection and Affordable Care Act (PPACA) in 2010, we have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. I dare say that Brahma, Vishnu and Shiva together would struggle to accomplish those lofty goals. Regardless of the daunting task in front of them, the brave policy gods who see patients about as often as they see pink unicorns, chose to release the Kraken – I mean the ACO – onto an unsuspecting public based on the assumption that anything was better than letting those big, bad, test ordering, hospital admitting, brand name prescribing physicians from running amuck.
I realize I am being somewhat harsh towards the creators of the ACO morass. But, while they all may be well-meaning, hard-working folks that own a Harvard crimson sweater, their intent is to fundamentally change how health care is provided – this mandates a withering evaluation. As Milton Friedman aptly said, “One of the great mistakes is to judge policies and programs by their intentions rather than their result.” Thus, with little regard to intent, and with an eye on the end result, I say unequivocally : ACO’s do not work.Continue reading…
I read with interest a recent editorial that opined on the poor evidence for screening in cancer trials. The evidence was judged poor because apparently no screening trial has demonstrated a clear reduction in all-cause mortality, only disease-specific mortality. One example discussed in the analysis reviews the data for colon cancer screening and notes that, while there were a statistically significant lower number of deaths related to colon cancer in the screened group, the total mortality in the two groups was no different. The authors posit that the study is either underpowered for total mortality or that the screened patients may have more deaths due to the ‘downstream effects’ of screening. The provocative conclusion by many a tweet and retweet is that cancer screening has not been shown to save lives. Apparently the path to progress in medicine now must be paved by studies with millions of patients. I understand the desire for more and more data, but I see danger in the sanctimonious protestations of those who can only find truth within the confines of a million-person, randomized control trial. This approach ignores the history of advances in clinical medicine, most of which live far outside of the boundaries of million-strong randomized clinical trials.