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Tag: David Williams

Are Decision Support Tools Turning Doctors into Idiots?

A HealthLeaders article by Gienna Shaw notes that some physicians are reluctant to use computerized decision support (CDS) tools because they fear losing the respect of patients and colleagues. There’s some evidence to support this concern:

In one [study], even tech-savvy undergraduate and graduate computer science students preferred physicians who rely on intuition instead of computer aids.

“Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them,” [study author James] Wolf says.

Shaw argues that this is a transient phenomenon in any case because soon everyone will use CDS as payers demand it and the tools get built in to electronic medical records in a way that’s invisible to patients. She’s probably right, but she’s sparked some interesting thoughts.Continue reading…

Primary Care Workforce Situation: Not Hopeless

I sometimes observe that the only sector of the economy as messed up as health care is higher education, where the US has some great institutions but where costs are incredibly high and have been rising relentlessly for long periods of time. These two dysfunctional systems intersect in multiple places, one of which is the cost of medical school and its impact on the physician workforce.

One of the reasons the cost of health care is so high in the US is the overemphasis on specialists vs. primary care relative to other advanced countries. That overemphasis is a result of multiple factors, including a reimbursement system that favors procedures and the prestige associated with specialties. But another significant factor is the cost and financing of medical school. Average debt levels for graduating medical students are around $150,000. Combine that with leftover debt from college and it’s easy to get up into the $200,000 range. That’s a big nut to pay off in primary care where typical compensation is $150,000 per year or so.

That large debt level certainly encourages graduating medical students from going into primary care. My guess is it also deters some would-be primary care physicians from going to medical school in the first place.Continue reading…

Death Panels Everyone Can Live With

Chief among Sarah Palin’s assaults on truth and reason is her contention that providing reimbursement for end-of-life planning sessions with a health care provider is tantamount to a “death panel” where a “bureaucrat can decide based on a subjective judgment of [a person’s] ‘level of productivity in society,’ whether they are worthy of health care.”

A Health Affairs article (Palliative Care Consultation Teams Cut Hospital Costs for Medicaid Beneficiaries) makes a far more level-headed and evidence-based contribution to the discussion. The authors studies the use of palliative care teams at four urban hospitals in New York State. To be clear on what these teams do:

Palliative care aims to relieve suffering and improve quality of life for patients with advanced illness and for their families. It does so through assessing and treating pain and other symptoms; communicating about care goals and providing support for complex medical decision making; providing practical, spiritual, and psychosocial support; coordinating care; and offering bereavement services.

Palliative care is provided in conjunction with all other appropriate medical treatments, including curative and life-prolonging therapies. It is optimally delivered through an interdisciplinary team consisting of appropriately trained physicians, nurses, and social workers, with support and contributions from other professionals as indicated.Continue reading…

Difficulties With Diagnosis

I’m impressed that the Boston Globe printed a number of insightful letters in response to its Mistakes that matter
article, which discussed the case of two patients whose prostate cancer
biopsies got mixed up. (One had cancer, the other didn’t. The one
without cancer got surgery as a result of the mixup, the one with
cancer had delayed treatment and possibly negative consequences as a
result.)

Two of the four letters are from patients who were tested for
cancer. The best is one from Irving Sacks of Peabody, documenting how
he searched widely for alternative treatments after being diagnosed
with cancer of the esophagus. In the end he found out from a medical
center in California that he had another condition –not cancer– and
didn’t need the proposed surgery to remove his esophagus. He says (and
I concur):

When confronted with a life-threatening
medical assessment, do not rely on a single diagnosis, and, when
getting a second opinion, go outside the network, even to another city.

Edgar Dworsky of Somerville wasn’t persuaded that he had prostate
cancer after the first pathologist said the slides were “suspicious for
cancer,” so he took the same slides to another pathologist who said he
“definitely” had prostate cancer and a third who said the slides were
“highly suspicious for prostate cancer.” Based on that set of findings
he’s decided he doesn’t (yet) have prostate cancer and has embarked on
a program of watchful waiting rather than active treatment. At least
from what he’s written it’s a little hard to follow his logic but for
his sake I hope he’s right.

Continue reading…

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