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Tag: Michael Millenson

The Dangerous Patient Safety Delusions of Eminence-Based Medicine

The eminent physicians Martin Samuels and Nortin Hadler have piled onto the patient safety movement, wielding a deft verbal knife along with a questionable command of the facts.

They are the defenders of the “nobility” of medicine against the algorithm-driven “fellow travelers” of the safety movement. On the one side, apparatchiks; on the other, Captain America.

They are the fierce guardians of physician autonomy, albeit mostly against imaginary initiatives to turn doctors into automatons. By sounding a shrill alarm about straw men, however, they duck any need to define appropriate physician accountability.

Finally, as befits nobility, they condescend to their inferiors. How else to explain the tone of their response to the former chief executive officer of Beth Israel Deaconess Medical Center, Paul Levy? As for patients, Samuels and Hadler defend our “humanity.” How…noble.

To me, healing the sick is an act of holiness, not noblesse oblige. Fortunately, we Jews cherish a long tradition of arguing even with God Himself. A famous Talmudic story ends with God acknowledging that even Divine opinion isn’t enough to override the rule of law. Let’s take a closer look at Samuels’s and Hadler’s opinions in relation to the rules of medical evidence.Continue reading…

Key for Health IT Entrepreneurs: Don’t Disrupt the Wrong Thing

millenson-headshotAmong the 200 demos, 60 exhibitors and more than 100 speakers at the annual Health 2.0 conference on digital health, a critical insight for succeeding in this burgeoning market might have gotten lost in the noise.

The crucial advice came on separate days from two of the savviest digerati doctors in Silicon Valley. Not coincidentally, both Dr. Robert Wachter and Dr. Michael Blumpractice at the University of California, San Francisco (UCSF) Medical Center.

Wachter, an internist, was an early and eloquent advocate of the potential of electronic health records (EHRs) to improve the safety and quality of care. Actual EHR implementation, however, brought not nirvana, but a jarring number of “side effects.” Not least was the way the technology often distracts, confuses and complicates the lives of clinicians, endangering patients in the process.

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Diagnostic Error: The IOM Talks Trash (But Not Cash)

flying cadeuciiTo understand how a landmark new report on diagnostic error breaks the mold, go past the carefully crafted soundbite ­(“Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences”) and rummage around the report’s interior.

You can’t get much more medical establishment than the Institute of Medicine (IOM), also called the National Academy of Medicine, author of the just-released Improving Diagnosis in Health Care. Yet in a chapter discussing the role played in diagnostic accuracy by clinician characteristics, there’s a shockingly forthright discussion of the perils of age and arrogance.

“As clinicians age, they tend to have more trouble considering alternatives and switching tasks during the diagnostic process,” the report says. Personality factors can cause errors, too: “Arrogance, for instance, may lead to clinician overconfidence.”

Wow. Sure, both those assertions are extensively footnoted and hedged later with talk of the importance of teams (see below). Still, given the source, this practically qualifies as “trash talking.”

Of course, those quotes didn’t make it into the press release. There, inflammatory language was deliberately avoided so as not to give opponents any easy targets. (Disclosure: I was an advocate of an IOM report on this topic while consulting to an organization that eventually helped fund it. After testifying at the first committee meeting, I had no subsequent involvement.)Continue reading…

How to Out-Argue Your Doctor with Data

Your doctor believes he’s “patient-centered” because he wants to provide the the treatment he thinks you need as quickly as possible. Or as the fictional Dr. Heart tells his chest pain patient right after recommending a stent, “As it happens, I can do the procedure for you next week. Does that work for you?”

Before giving in to the gurney, what questions should patients ask? One data-driven script was presented in skit form at the recent Health Datapalooza 2015 meeting in Washington, D.C. The drama was light-hearted; the clinical and financial issues underlying it are not.

Dr. Heart was played by Glyn Elwyn, a theater student-turned-family practitioner recognized as one of the world’s leading researchers in patient preferences and values. Casey Quinlan, a writer and activist widely known for her unfiltered expression of those preferences and values, played the patient.

In the skit, a persistent Quinlan keeps pestering the doctor with questions about what a stent will accomplish that changing her medications won’t. At first glance, a stent sounds appealing because it props open the blood vessel. What could be better? However, when Quinlan asks directly about the effect of meds versus stenting on preventing a heart attack, the doctor admits that data show medication lowers the odds but stenting does not.

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The “Business Case” For Patient Safety

Betsy Lehman

Twenty years ago this month, the Boston Globe disclosed that health columnist Betsy Lehman, a 39-year-old mother of two, had been killed by a drug overdose during treatment for breast cancer at Dana-Farber Cancer Center. In laying out a grim trail of preventable mistakes at a renowned institution, the Globe prompted local soul searching and a new focus on patient safety nationally.

Although I didn’t know Betsy personally, we were about the same age, had two kids about the same ages and were in the same profession. (I, too, was a health care journalist.) That’s why I was particularly disappointed by a recent conference celebrating the reopening of the Betsy Lehman Center for Patient Safety and Medical Error Reduction. It was heavy on statistics and poll results; e.g., one in four Massachusetts adults say they’ve seen an error in their own care or the care of someone close to them.

While it’s true that Boston is the epicenter of thinking, writing and speaking about patient safety, words do not always translate into deeds.

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Race, Ethnicity and Patient Engagement

flying cadeuciiA few years ago, I was upgraded to First Class on a flight from California back to Chicago. Not long after I settled in, a tall, muscular man easily four inches taller than me walked up to my aisle seat in the first row and prepared to sit by the window.

I envisioned him spending hours hemmed in by the bulkhead and offered to switch places. We began to talk, and soon he shared that his seatmates often hesitate to engage him in conversation. Women and even some men will turn or stiffen in their seats in order to send a clear body-language message.

That’s what happens when you’re a large, physically imposing black guy. People make assumptions. When it comes to patient engagement, we often make assumptions, too.

We minimize the influence of race, gender and ethnicity, or we confuse it with socio-economic status. We assume that “people like us” have communication preferences like us. We downplay the doctor-patient relationship and overemphasize technology.

Race and Ethnicity Matter

In truth, race and ethnicity matter as much in medicine as in the rest of the society. For example, whites, African-Americans and Latinos share the same expectations of their physicians, a study in Health Services Research found, but “patients from different racial and ethnic groups report differing experiences…when using well-validated measurement tools.” Translation: the perception reflects reality.

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The Medical Home’s Humpty Dumpty Defense


I was reading a medical home advocacy group’s upbeat approach to a recent JAMA study that had found scant benefit in the concept when, suddenly, we tumbled into Alice in Wonderland territory.

The press release from the leadership of the Patient-Centered Primary Care Collaborative (PCPCC) started out reasonably enough. The three-year study of medical practices had concluded that the patient-centered medical home (PCMH) contributed little to better quality of care, lower cost and reduced utilization. This was an “important contribution,” said the PCPCC, because it showed “refinement” of the concept that was still necessary.

That was just the set up, though, to this challenge from Marci Nielsen, chief executive officer of the group. “It is fair,” said Nielsen, “to question whether these pilot practices (studied) had yet transformed to be true medical homes.”

Where might one find these true medical homes? The answer turns out to be as elusive as a white rabbit. Formal recognition as a medical home via accreditation “can help serve as an important roadmap for practices to transform.” However, accreditation as a PCMH “is not necessarily synonymous with being one.” Conversely, you can be a “true PCMH” without having received any recognition at all!

But maybe the true medical home does not yet exist, since, “the evidence base” for the model “is still being developed.”

In Through the Looking Glass, Humpty Dumpty scornfully informs Alice: “When I use a word, it means just what I choose it to mean – neither more nor less.” And so we learn that a true medical home means just what the PCPCC says it does.

It’s confusing. If the truly transformational medical home lies in the future, why does the PCPCC chide the JAMA researchers in this “otherwise well-conducted study” for failing to “reference the recent PCPCC annual report which analyzed 13 peer-reviewed and 7 industry studies and found cost savings and utilization reductions in over 60 percent of the evaluations”?

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GOP’s Oddest Obamacare Rejection: “Patient-Centered Healthcare”

The reason that Republicans shut down the federal government, it turns out, was to “restore patient-centered healthcare in America.”

Huh?

As the lead author of a policy paper entitled, “Will the Affordable Care Act Move Patient-Centeredness to Center Stage?” I admit to a certain guilty thrill when I read this precise demand coming as the climax of a letter sent by 80 hard-right representatives to House Speaker John Boehner (R-OH). You don’t get much more “center stage” than shutting off the federal money spigot, which is what the letter – discussed in a recent article in The New Yorker – threatened unless the ACA was defunded.

Having said that, patient-centeredness was a truly odd choice to occupy a central role in the conservative casus belli that ended up disrupting the entire U.S. economy until the right wing finally caved.

To begin with, the term is a minor piece of jargon likely to draw blank stares from pretty much the entire American public. Even for us health policy mavens, the GOP letter linking James Madison on the redress of grievances to defunding Obamacare to a “restoration” of patient-centeredness required major mental gymnastics.

Then there’s the unintentional linguistic irony. The term “patient-centered medicine” originated after World War II with a psychoanalyst who urged physicians to relate to patients as people with physical and psychological needs, not just a bundle of symptoms. “Patient-centered care” further defined itself as exploring “patients’ needs and concerns as patients themselves define them,” according to a book by the Picker/Commonwealth Program for Patient-Centered Care, which coined the term in 1987. Patient-centered care was adopted as a “goal” by the Institute of Medicine, which added its own definition, in 2001.

But here’s where the irony kicks in. Obamacare opponents assert that the ACA undermines the traditional doctor-patient relationship – although I suspect that being able to pay your doctor because you have health insurance actually improves it quite a bit.

Yet in calling for “patient-centered healthcare” instead of the more common “patient-centered care” or even patient-centered medicine, conservatives unwittingly abandoned doctor-patient language in favor of business-speak.

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Still Demanding Medical Excellence

Forget for a moment the familiar scenes of action and outraged reaction that are playing out in our long-running national debate over how best to provide access to health care for every American. Instead, ask one simple question: what happens in the doctor’s office or hospital once access is achieved.

I set out to write a book addressing that question almost twenty years ago. I thought myself well qualified: I’d written about health care for a decade for the Chicago Tribune while receiving various awards and other recognition. But it didn’t take long for a painful realization to set in of how naïve I really was.

Digging through hundreds of studies, articles and other first-hand sources stretching back for decades, I was stunned to discover that repeated evidence of unsafe, ineffective, wasteful and downright random care had had no effect whatsoever on how doctors treated patients. Literally none. Moreover, the few professionals who understood this truth couldn’t talk about it in public without endangering their careers or engendering vitriol from peers.

Fortunately, I had no academic or clinical career to imperil. In the conclusion to Demanding Medical Excellence: Doctors and Accountability in the Information Age, I gave vent to anger and indignation. I wrote:

From ulcers to urinary tract infections, tonsils to organ transplants, back pain to breast cancer, asthma to arteriosclerosis, the evidence is irrefutable. Tens of thousands of patients have died or been injured year after year because readily available information was not used ­– and is not being used today – to guide their care. If one counts the lives lost to preventable medical mistakes, the toll reaches the hundreds of thousands.

The only barrier to saving these lives is the willingness of doctors and hospital administrators to change.

Demanding Medical Excellence came out in October, 1997. What progress has been made since then, and where we have fallen short? I address that question in a short article, “The Long Wait for Medical Excellence,” in the October, 2013 issue of Health Affairs. The purpose of this blog entry is to recap some of what’s said there (for you non-subscribers) and to add a few impolite observations that don’t jibe with the rules of a peer-reviewed journal.

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The 9th Grade Class Does Obamacare Math (Can Journalists Do the Same?)

Welcome, students, to our special combined 9th grade math and civics class. Today, we’re going to look at the “Cadillac tax” in the Affordable Care Act.

Yes, Mitt, you have a question already? No, no, “Cadillac tax” is just an expression. No one is going to tax your family’s cars, Mitt, I promise.

Paul, you also have a question? I’m sorry, Paul, but if you had done the reading, you would know that the “Affordable Care Act” and “Obamacare” are the same thing. And yes, it is still the law, as I must have told you and your friends 40 times. Now can we get on with the class?

As those of you who did do the reading know, most American workers get their health insurance through their employer. The company, in turn, is allowed to deduct the cost of that insurance from its taxes. If the insurance for workers is very generous, it can encourage people to use too much medical care. This not only drives up costs, but we all pay for it a second time through the tax code. The Affordable Care Act addresses that problem by placing an excise tax on rich benefit plans starting in 2018, which is informally known as the “Cadillac tax.”

Economists of all viewpoints generally agree that an open-ended tax deduction for health insurance encourages overconsumption. What do we call that kind of agreement? Michelle?

No, Michelle, I’m afraid, “liberal conspiracy” is not the answer I was looking for. “Bipartisan consensus” was the correct response.

Rand, you seem quite agitated. Yes? “Government intervention in markets is never the right answer.” OK. Well, Rand, let’s talk about that another time and move on from civics to the mathematics part of today’s lesson. We’ll start with a word problem from the New York Times.

The Times quoted a study from a health policy journal as saying that 75 percent of health plans could be affected by the Cadillac tax over the next decade. That’s a big number, isn’t it?  And the tax itself is 40 percent – another big number. No wonder the story was on the first page of the Business section.

But here are a few other numbers from the same study: just 16 percent of plans are likely be affected by the tax when it starts in 2018 ­– a much smaller number. And the “next decade” the study is talking about starts in 2018. What the study actually says is that by 2029 the tax could reduce benefits for affected plans by 3.1 percent. That’s an even smaller number and even further away.

Class, why would the New York Times emphasize the biggest numbers they could find?

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