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The CSI Effect Hits Medicine

By EVAN FALCHUK

I’m in Israel, home to some of the most innovative care in the world.  Doctors here wanted to know if the high-tech tests that are an increasing part of their work helps.  A couple of weeks ago, they published their results.

It turns out that in about 90% of cases, it didn’t matter.

A physical exam, the patient’s history, and the basic set of tests that doctors have done for decades was almost always all that was needed to get a diagnosis.  As one of the doctors in the study put it, “ basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases.”

The conventional wisdom is that doctors – at least in the U.S. – order extra tests to protect themselves from getting sued.  But this study was done in Israel, where the problem of medical malpractice is nothing like it is in the U.S.  American-style defensive medicine can’t be the reason doctors in Israel use so many diagnostic tests.

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JAMA EHR Study: Misdiagnosis Poses Significant Potential for Harm

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By Evan Falchuk

An important study in the Journal of the American Medical Association finds that misdiagnosis is more common than you might think.  According to the study, almost 40% of patients who unexpectedly returned after an initial primary care visit had been misdiagnosed.  Almost 80% of the misdiagnoses were tied to problems in doctor-patient communication, and more than half of those problems had to do with things that were missed in the patient’s medical history.

The results of this study shouldn’t be surprising if you’re a regular reader here – they are another example of a system that isn’t working as well as it could for patients, and doctors.  Doctors – and the medical professionals who help them in their work – are the best educated and best trained than they have ever been.  They have more access to medical information and technology than at any time in our history.  And yet, U.S. government data show that the typical doctor visit involves 15 minutes or less with your doctor.  Medical records are kept in fragmented, uncoordinated ways.

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Building a Better Health Care System: Should We Be Tracking Misdiagnosis?

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By Evan Falchuk

If you study misdiagnosis you realize how often patients get the wrong diagnosis.

But what do expert doctors think about how often it happens? And what do they think can be done to address it?

We wanted to find out so we partnered with the National Coalition on Healthcare to conduct a landmark, nationwide survey. We surveyed 400 cancer specialists from our Best Doctors database – and the findings were provocative.

The survey, “Exploring Diagnostic Accuracy in Cancer: A Nationwide Survey of 400 Leading Cancer Specialists,” focused on what doctors believe to be the most significant barriers in efforts to accurately diagnose cancers; the types of cancer they believe are most often misdiagnosed; and the tools and improvements they most need to combat misdiagnosis.

One of the most surprising findings was on how often doctors believe misdiagnosis happens. While published studies show that misdiagnosis occurs in about 15-28% of cases, the large majority of doctors we surveyed thought it happens in less than 10% of cases. At the same time, doctors recognized that the root causes of misdiagnosis were very prevalent – fragmented medical information, disparities in experience among pathologists and other factors.

So – how to explain the difference in doctors’ perceptions and the published research? I think it is because there is no systematic feedback loop for doctors letting them know of inaccuracies in their care. If you diagnose someone and they go on to get treatment someplace, and it’s later discovered that a diagnosis wasn’t exactly right, the original doctor may never find out about it. If you don’t hear about it, you can’t be blamed for thinking this problem is rare. It also means you miss out on the opportunity to improve the quality of care that these cases represent.

Another interesting point. Doctors reported that, regardless of how often they thought diagnostic inaccuracies happened, it is a problem that needed more attention from policy-makers. As NCHC President and CEO John Rother observed, “Not enough is being done on the state and federal policy end of things to acknowledge and firmly address this critical issue. Given our current health care climate and challenges, as decision-makers become more aware of the frequency of misdiagnosis and the enormous costs associated with it, they have a sizeable opportunity to make diagnostic accuracy much more of a ‘front and center’ issue in health care.”

Here’s to that promising thought.

Evan Falchuk is Vice Chairman of Best Doctors, Inc., where this post originally appeared. Prior to joining Best Doctors, Inc., in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases. This post originally appeared on Best Doctors, Inc.’s See First Blog.

It Doesn’t Have to Be This Way …

By Evan Falchuk

I was struck by the recent story in the New York Times about a young boy who was misdiagnosed, and lost his life.

The boy, Rory Staunton, was a healthy, active 12-year old, until one day he ended up in the middle of our time-strapped, broken healthcare system.  He was treated by good, well-intentioned doctors, at a leading medical center, but something went terribly wrong.  What started out as a minor cut suffered in a basketball game turned into a major infection that took his life.

Yet nowhere along Rory’s journey, from boy with a bellyache on Thursday to gravely ill boy on Friday night, did anyone act on strong indications that he might be fighting for his life. Critical information gathered by his family doctor and during his first visit to NYU Langone was not used, was not at hand or was not viewed as important when decisions were made about his care, records show.

Story’s like Rory’s happen far too often, and in far too familiar ways.  Scientific studies show that patients are misdiagnosed between 15% and 44% of the time.  Researchers have found that the combination of fragmented medical information and not enough time between doctor and patient are the leading causes of this problem.  And yet, much of America is still unaware how often misdiagnosis happens.  Lost in all the politics of healthcare is a recognition that, at its core, healthcare must be about making sure each and every patient gets the right care.

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Health Care As Economic Engine?

By Evan Falchuk

Former Office of Management and Budget (OMB) Director Peter Orszag is sounding a pretty serious alarm about American health care expenses lately. In the current issue of Foreign Affairs, he writes:

“The Congressional Budget Office (CBO) projects that between now and 2050, Medicare, Medicaid, and other federal spending on health care will rise from 5.5 percent of GDP [gross domestic product] to more than 12 percent. … It is no exaggeration to say that the United States’ standing in the world depends on its success in constraining this health-care cost explosion; unless it does, the country will eventually face a severe fiscal crisis or a crippling inability to invest in other areas.”

Are health care costs going to cripple America’s economy? Or could the polar opposite be true – that they are they really the overlooked engine of job growth for America’s 21st-century economy?

Consider China, a country transitioning into a modern economy, led by manufacturing. Manufacturing as a percentage of the Chinese economy today dwarfs the percentage from even 20 years ago. At this rate, manufacturing by 2050 will have all but consumed the Chinese economy, crippling its ability to invest in other areas.

It’s not outrageous to say a parallel can be drawn here with American health care.

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5 Ways You Can Avoid Being Misdiagnosed

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By EVAN FALCHUK

Billionaire Teddy Forstmann has apparently been diagnosed with a serious form of brain cancer.  There’s a tragic twist to the story: according to Fox Business News, Forstmann believes that for more than a year, he had been misdiagnosed with meningitis.

ABC News wonders:

How could such a misfortune befall a billionaire —- a man able to afford the best doctors, best technology and the most sophisticated diagnostic tests?

They’re missing the point.  Misdiagnosis happens with shocking regularity – as much as 44% of the time, depending on the illness.

I’m sure that, as with most things, being a billionaire is better.  But as a neurosurgeon quoted by ABC News points out, even for a billionaire, getting the right care is “still a bit of a crap shoot.”

So how can you improve your odds?  Here are 5 tips that work.

1.  Know your family history – and remind your doctor of it. Don’t assume your doctor remembers that time you told him that two of your aunts died of breast cancer, or that your grandfather and father have a history of malformed blood vessels in their brains.  Research studies have shown that a family history may be a better predictor of disease than even genetic testing.  Find out about your family’s medical history, write it down (the Surgeon General has a good on-line tool to help you do this), and make sure your doctor knows about it – especially if you’re sick and they’re trying to decide what’s wrong.

2.  Ask questions.  The typical doctor sees as a many as 40 patients a day, spending 15 minutes or less with each one.  It’s all too easy to be referred to a specialist and start treatment without having all of your questions answered.  But asking questions won’t just make you feel more comfortable – it can disrupt your doctor’s thought process and make him think about your case in a way that may save your life.  Dr. Jerome Groopman, one of the world’s foremost researchers on how doctors think (he’s written the definitive book on it) agrees:

“Doctors desperately need patients and their families and friends to help them think. Without their help, physicians are denied key clues to what is really wrong. I learned this not as a doctor but when I was sick, when I was the patient.”

You can find some useful tips on how to do this at the U.S. government’s web site, called “Questions are the Answer.”

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Don’t Stop Medical Innovation

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By EVAN FALCHUCK

The New York Times says “In Medicine, New Isn’t Always Improved.”

Who can argue with this?

“In Dining, New Restaurants Aren’t Always Better.”

Yes, that’s true, too.  But does it mean anything?

The article is about a type of hip that is apparently going to be the focus of a lawsuit.  The story goes that a lot of people wanted the new hip when it came out, because it was thought to be better than the older ones.  Unfortunately, the hip seems to have hurt some people, some of whom may have been better off getting the older one in the first place.

A doctor quoted in the article suggests it’s part of a uniquely American tic.  We want all of the latest and greatest things for ourselves, it seems.  This story is supposed to be a cautionary tale of what can go wrong when we do.

On the other hand, the latest and greatest things don’t appear out of nowhere.  In America, when people demand something, there will be someone who supplies it.

It’s true.  Doctors, researchers, the government, and, yes, for-profit companies, create things.  They invent diagnostic tests and treatments for disease that never existed before.  One reason why the U.S. has a trillion-dollar health care economy is because there are so many people creating so many new things that people can sanely talk about curing – or at least managing – all disease.  This is a good thing.

But all these breakthroughs are a two-edged sword.

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The Future of American Healthcare, Ctd

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By EVAN FALCHUK

Almost half of health plans in the US have deductibles of at least $1,000 according to a new study.  It’s called “cost shifting” and it’s a big part of the future of American health care.

There are two major reasons why employers are doing this.

First, higher deductible plans are cheaper, since there is less risk to insure.  Think of your car insurance – why would you make a claim for a ding on your door when it’s cheaper for you to just pay to have it fixed (or fix it yourself)?  The higher the deductible, the lower the premium, even if it means more out-of-pocket cost for you for the small stuff.

Along these same lines is the second reason.  If employees spend more of their own money on health care, maybe they’ll be smarter about how they spend it.

It sounds good – but does it work?

Yes.  And No.

Studies show that consumers in high-deductible health plans do spend less than those in traditional plans.  But, they spent less in some worrisome ways:

Childhood vaccination rates dropped. . .Rates of mammography, cervical cancer screening, and colorectal cancer screening also fell among those with high-deductible health plans relative to those in traditional plans. . . . even though high-deductible plans waive the deductible for such preventative care.

As another study put it: “Deductibles can create powerful yet potentially indiscriminate and blunt incentives for consumers to alter their care-seeking behavior.”

Of course, this is a complicated way of saying higher deductibles work, and are smart choices for employees and their employers.  But the research tells us they aren’t enough.

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Costs are Up…Because They’re Higher Than They Were

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By EVAN FALCHUK

In perhaps no other country is there a greater abundance of data about health care than there is in the United States.  And in perhaps no other country is there more confusion as to what’s really going on.

Take the recent report by powerhouse actuarial firm Milliman (disclosure:  Best Doctors uses Milliman for actuarial work).  It’s a fascinating report with some of the best information on American health care there is.

The major take-away:  U.S. health care costs continue going up.

But when people start interpreting the data, well, that’s where the trouble starts.

For example, NPR reports on why costs are going up:

For three straight years, outpatient care has led all other categories of care in cost increases. Ninety percent of the increase is in more types of care being delivered in outpatient settings.

Factually, of course, this is correct.  More and more care is being delivered in outpatient settings.Continue reading…

The Doctor is…Overbooked

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By EVAN FALCHUK

At the New York Times’ City Room Blog, Joel Cohen writes:

my wife and I are convinced that all medical students should have to pass Overbooking 101 before they can become doctors.Again and again, we arrive at a doctor’s aptly named waiting room on or before the scheduled time, only to learn that three or four others sitting there have been given the same appointment.

He says doctors need to understand the impact of this on their patients.  I agree, but not just because it’s annoying.

A typical doctor sees thirty patients a day.  Some see even more.

Reflect on that math.  If your doctor sees 30 patients a day, that’s 150 a week, 600 a month, maybe 7,000 a year.

It means that if it’s been even two months since you last saw your doctor, he has probably seen more than a thousand people since your last visit.  It’s why there’s often that moment of disconnect when you see your doctor.  You’re living every day with the fears and anxieties of your medical condition, but your doctor can’t quite place which one of the worried patients you are.  So you have to remind him why he ordered that extra test a few months ago, why you switched medications the last time you were there, how he already ruled out that possibility the last time he saw you.Continue reading…