Tag: FutureMed

Would You Get a Brain Implant if It Could Make You Smarter?

Apr 22, 2014• 3

By Hillary Schaub

Yesterday the Pew Research Center’s Internet & American Life Project released the findings of their survey on the future of science. 1,001 participants were read a list of scientific innovations that may or may not happen in the next 50 years.

The respondents reported how likely these innovations were to occur, whether they believed such a change was a positive development, and whether they would personally use these new technologies.

Here are some highlights from the survey:

Custom Ordering Organs
Americans are confident that people in need of an organ transplant will have new ones custom made for them in a lab. 22 percent of Americans say that scientists will definitely be able to custom make organs for those in need, 60 percent think it will probably happen. Only 15 percent of Americans think it will probably or definitely not happen.

Controlling DNA
Americans are not fans of genetic engineering. 66 percent of respondents say that we will be worse off if prospective parents can alter the DNA of their children to produce smarter, healthier, or more athletic offspring. About one-in-four Americans think scientists striving to create perfection by developing the ability to control the DNA of offspring would be a positive change.

Growing Meat
A large percentage of those surveyed are turned off by the thought of test tube meat. 78 percent of Americans would not eat meat that was grown in a lab. 22 percent of Americans reported they were comfortable eating lab grown meat.

Rebooting Primary Care From the Bottom Up

Apr 16, 2014• 53

By Zubin Damania, MD

For the better part of a decade, I practiced inpatient hospital medicine at a large academic center (the name isn’t important, but it rhymes with Afghanistan…ford).

I used to play a game with the med students and housestaff: let’s estimate how many of our inpatients actually didn’t need hospitalization, had they simply received effective outpatient preventative care. Over the years, our totals were almost never less than 50%.

For my fellow math-challenged Americans: that’s ONE HALF! Clearly, if there were actually were any incentives to prevent disease, they sure as heck weren’t working.

In a country whose care pyramid is upside down—more specialists than primary care docs, really?—we’re squandering our physical, emotional, and economic health while spending more per capita than anyone else. Four percent of our healthcare dollars go towards primary care, with much of the remaining 95% paying for the failure of primary care. (The missing 1%? Doritos.)

Worse still, the oppressive weight of our non-system’s dysfunction falls disproportionately on the shoulders of our primary care providers—the very instruments of our potential salvation. To them, there’s little solace (and plenty of administrative intrusion) in the top-down reform efforts of accountable care organizations and “certified” patient-centered medical homes.

But what about a bottom-up, more organic effort to reboot healthcare? A focus on restoring the primacy of human relationships to medicine, empowering patients and providers alike to become potent, positive levers on a 2.8 trillion dollar economy? What if we could spend twice as much on effective, preventative primary care and still pull off a net savings in overall costs, improvements in quality, and increased patient satisfaction?

What if George Lucas had just quit after the original Star Wars series? Wouldn’t the world have been better without Jar Jar Binks?

While the latter question is truly speculative, the former ones aren’t. We’re trying to answer them in Las Vegas (hey now, I’m being serious) at Turntable Health, where we’ve partnered with Dr. Rushika Fernandopulle and Cambridge, MA based Iora Health.

We aim to get primary care right by doing the following:

Continue reading…

Open Notes: Is Sharing Mental Health Notes with Patients a Good Idea?

Apr 11, 2014• 13

By MICHAEL KAHN, MD

Would allowing patients to read their mental health notes provide more benefits than risks?

In a recent article in JAMA my colleagues and I argue that it would. While transparent medical records are gaining favor in primary care settings throughout the country through the OpenNotes initiative, there has been reluctance to allow patients to see what their treaters say about their mental health issues. While this reluctance is understandable and deserves careful consideration, we suggest that several benefits could result from patients reading their mental health notes.

First of all, accuracy would be enhanced by allowing patients to cross-check what their clinicians say about their symptoms, medication doses, and so forth. Second, allowing patients to review assessments and treatment decisions privately might help to promote a richer dialogue between patient and clinician. Third, patients might learn that their clinician sees them more as a complete person, rather than as a collection of symptoms.

Many patients silently fear that their treater “will think I’m crazy/whining/lazy/boring”; seeing in print that the treater does not see them that way—and in fact recognizes and documents their strengths—can be an enormous relief and might therefore enhance the therapeutic alliance.

Clinicians have their own worries about transparent mental health notes that must be considered. Will patients feel objectified by the medical language commonly used in documentation? Will they break off treatment if they don’t like what they read? Will too much time be spent wrangling over details of what has been documented? Will vulnerable patients be psychologically harmed by reading their notes? Although our article briefly addresses these issues, only a trial of transparent mental health notes will provide the data needed to assess them.

Such a trial has just begun at the Beth Israel Deaconess Medical Center in Boston. Culminating many months of careful planning by my colleagues in the ambulatory psychiatry clinic, the Social Work department, as well as the OpenNotes team, we began a pilot project of transparent notes in our psychiatry clinic on March 1. So far almost all clinicians have chosen to participate in the project, and have identified 10% of their caseloads to be included. It’s too early to gauge results yet, but we hope to more fully evaluate the effects of making mental health notes fully transparent to our patients.

Michael W. Kahn, MD is an assistant professor of psychiatry at Harvard Medical School and Harvard Medical Faculty Physician at Beth Israel Deaconess Medical Center (BIDMC).

Are We Prepared For The Next Viral Disease Threat?

Apr 6, 2014

By Weaver, Gallo & Hrynkow

Fred Shaw went to St. Martin and all he got was a painful virus called chikungunya.

On an island stop during his Caribbean cruise vacation, Mr. Shaw was infected with the mosquito-borne virus that causes a severe fever and an arthritis-like condition in people, similar to dengue fever. After infection, the virus still may cause long periods of fatigue and incapacitating joint pain.

Writing on Facebook, Mr. Shaw said, “The fever, leg rash and swelling were bad enough, but then followed by months of headache, joint pain and malaise, I finally have gotten over it (I think).”

Chikungunya virus was first described during an outbreak in Tanzania in 1952 and was subsequently discovered in other parts of Africa and Asia. The name ‘chikungunya’ is derived from a local phrase that means ‘that which bends up’ and describes the stooped appearance of sufferers with joint pain.

In late 2013, chikungunya was found for the first time in modern history on islands in the Caribbean. Based on our research and the evidence we have observed, it is likely that the virus is on its way to the U.S.

Vector-borne viruses—which are transmitted to people by an animal or insect—threaten half the world’s population and are responsible for millions of human infections annually. Various mosquitoes and ticks transmit a subgroup of these viruses that are called arboviruses.

There are over 100 known arboviruses that infect humans and can cause neuroinvasive diseases like encephalitis, febrile illnesses and hemorrhagic fevers. Except for yellow fever, tick-born encephalitis and Japanese encephalitis, there are no commercially available vaccines for most arboviral disease.

As the world becomes flatter and the globe opens to new opportunities for international trade and travel, viruses that used to be confined to “over there” are increasingly coming “over here,” and they are arriving sooner rather than later.

Actually, High-Tech Imaging Can Be High-Value Medicine

Mar 6, 2014• 4

By Karan Chhabra

Lub-SHHRRR. Lub-SHHRRR. Lub-SHHRRR.

“Can you hear it?” she asked with a smile. The thin, pleasant lady seemed as struck by her murmur as I was. She was calm, perhaps amused by the clumsy second-year medical student listening to her heart.

“Yes, yes I can,” I replied, barely concealing my excitement. We had just learned about the heart sounds in class. This was my first time hearing anything abnormal on a patient, though it was impossible to miss—her heart was practically shouting at me.

Her mitral valve prolapse—a fairly common, benign condition—had progressed into acute mitral regurgitation. She came to the hospital short of breath because her faulty valve was letting blood back up into her lungs.

Though it was certainly frightening, surgery to fix the valve could wait a few weeks. But before doing anything, the surgical team wanted a picture of the blood vessels in her heart.

If the picture showed a blockage, the surgeons would have to perform two procedures: one to fix the blockage, and another to fix her valve. If her vessels were healthy, though, the surgeons could use a simpler approach focused just on her valve.

So she came to the interventional cardiologist who was teaching me for the day. Coronary angiograms are the interventionalists’ bread-and-butter procedure, done routinely to look for blockages and to guide stent placement. They involve snaking a catheter from the groin or arm through major blood vessels and up to the heart.

Under fluoroscopy (like a video X-ray), the cardiologists shoot contrast medium into the arteries, revealing the anatomy in exquisite detail.

The images are recorded electronically and accompanied by the cardiologist’s interpretation for anyone else who opens her medical record.

Though routine, these catheterizations aren’t trivial. Whenever you enter a blood vessel, you introduce the risk of bleeding and infection. Fluoroscopy is radiation, and contrast medium can damage the kidneys. And let’s not forget cost—reimbursing the interventional cardiologist, a radiology technician, and nursing staff costs Medicare almost $3,000 per case.

So I asked the cardiologist if such an invasive approach was really necessary.

Doctors Without State Borders: Practicing Across State Lines

Feb 24, 2014• 18

By Robert Kocher, MD

In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

The Current System And Its Drawbacks

State licensure of physicians has been widespread in the United States since the late nineteenth century. Licensure laws were ostensibly enacted to protect the public from medical incompetence and to control the unrestrained entry into the practice of medicine that existed during the Civil War. However, it no longer makes sense to require a separate medical license for each state.

Today, medical standards are evidence-based, and guidelines for medical training are set nationally through the Accreditation Council for Graduate Medical Education, the Centers for Medicare and Medicaid Services’ Graduate Medical Education standards, and the Liaison Committee on Medical Education. All U.S. physicians must pass either the United States Medical Licensure Examinations or the Comprehensive Osteopathic Medical Licensing Examination.

Although the basic standards for initial physician licensure are uniform across states, states impose a patchwork of requirements for acquiring and maintaining licenses. These requirements are varied and burdensome and deter doctors from obtaining the licenses required to practice across state lines.

Medical Students: The Anti-Millionaires

Feb 13, 2014• 17

By Daniel Coleman

A few months ago, CBS Moneywatch published an article entitled “$1 million mistake: Becoming a doctor.” Aside from the possibility that devoting one’s life to helping others might be considered a mistake, I was struck by the “$1 million” figure.

Was it actually that much? I mean, $1 million is a lot of money. When I was younger, millionaires seemed a rarefied breed. They drove expensive cars and had houses with names like “Le Troquet” or “Brandywine Vale.” The figure was supposedly calculated using the following factors:

The cost of school, inclusive of tuition, fees and insurance
The interest on the loans incurred to pay for the above items
The income lost by not working full-time for 10 years, assuming an average income of $50,000 per year

Before coming to medical school, I worked in the pharmaceutical industry. I even turned down a hefty promotion to start my education as soon as possible, rather than defer for a year or two.

Thus, my back-of-the-envelope calculations made it fairly obvious that, including benefits, bonuses, and potential promotions, my medical decision was not a $1 million mistake, but was more like a $1.3 million dollar disaster.

Of course, people tell me that I’ll be profitable and that I’m a good credit risk, but what I really am is one of a rarefied breed that drive economy cars and have houses with names like “Apt. #203.” What I really am is an anti-millionaire.

The Real Problem With Med Student Debt

Jan 28, 2014• 11

By Chhabra, Joseph & Herigon

America might never agree on how much doctors deserve to earn. But there ought to be much less debate on the immense debt today’s medical students incur on the way to becoming doctors.

Few people are more aware of the stress of medical student debt than med students themselves, and there’s evidence that it affects our specialty and practice decisions later on down the line.

Enter this tweetchat. What began as a typical med student complaint about their debt load evolved into a provocative discussion about the underlying factors and potential solutions to the debt problem.

We’ve incorporated some notes explaining perhaps unfamiliar concepts, but otherwise this is the unvarnished product of a few med students procrastinating on a Sunday night.

Allan Joseph (AJ): The easiest way to tell if med-student debt is becoming an acute problem is if the demand for medical-school spots (easily measured by the number of applicants) is declining relative to the supply. That’s just not happening. In fact, the opposite is.

IDESG Is a Glimpse of Our Digital Future

Jan 26, 2014• 3

By Adrian Gropper, MD

I’ve recently returned from the 7th ID Ecosystem Steering Group Plenary in Atlanta. This is an international public-private project focused on the anything-but-trivial issue of issuing people authoritative cyber-credentials: digital passports you can use to access government services, healthcare, banks and everything else online.

Cyber ID is more than a single-sign-on convenience, or a money-saver when businesses can stop asking you for the names of your pets, it’s rapidly becoming a critical foundation for cyber-security because it impacts the resiliency of our critical infrastructure.

Healthcare, it turns out, is becoming a design center for IDESG because healthcare represents the most diverse collection of human interactions of any large market sector. If we can solve cyber-identity for healthcare, we will have solved most of the other application domains.

The cyber-identity landscape includes:

proving who you are without showing a physical driver’s license
opening a new account without having to release private information
eliminating the risk of identity theft
civil or criminal accountability for your actions based on a digital ID
reducing your privacy risks through anonymous or pseudonymous ID
enabling delegation to family members or professional colleagues without impersonation
reducing hidden surveillance by state or private institutions
when appropriate, shifting control of our digital tools to us and away from corporations

The IDESG process is deliberate and comprehensive. It impacts many hot issues in health care including patient matching, information sharing for accountable care and population health, health information exchanges, prescription drug monitoring programs, accounting for disclosures, patient engagement and meaningful use, the physician’s ability to communicate and refer without institutional censorship, the patient’s ability to control information from our increasingly connected devices and implants, and more.

Hospitals and health industry incumbents that seek to solve the hot issues raised by health reform are not eager to wait for a deliberate and comprehensive process. For them, privacy and cyber-security is a nice-to-have. Who will pay for this digital enlightenment?

The Flu Shot and a Patient’s Right to Choose

Jan 25, 2014• 12

By Jennifer Anyaegbunam

Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s partnership with ThinkWellPoint. Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.

I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.

Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.

According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.

Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?

I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.

This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.

Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.