So one friend sent me this cool urban legend powerpoint about how coughing saves your life during a heart attack. The About.com page I’ve linked more or less debunks it, but another friend had a much better repost: 

I ride by bike to work, in Shanghai, where someone coughing and spitting is seen as completely normal, so while I might recover from the initial onset, it will attract zero attention. In my further bewidlerment, I will be run over by one of the drivers of the manifold Mercedes and prowling Porsches that care not an iota about human life, especially if on a bicycle (it’s a small dick thing).

My last few moments will be spent looking up at the assembled crowd of onlookers, who admiring the soles of my well heeled shoes, will be unable to reconcile the apparent wealth with biking to work. In my frustration, I will be unable to tell them that I cycle for my health.

Ironically after I spent last week sitting in with the Dartmouth crowd, on Friday the IOM (despite having a lack of Dartmouth folks on this committee!) came out with a recommendation for a New National Program To Evaluate Effectiveness of Health Care Products and Services and End Confusion About Which Work Best. In other words an American NICE. (Here’s the more digestible Retuers article).

All major Democratic proposals suggest such a thing, and it’s even something that I and Karen Ignagni can agree about.

"Patients deserve to know not only what medical treatments work, but which treatments work best," Karen Ignagni, president of America’s Health Insurance Plans, said in a statement. "With new treatments and technologies introduced each day, providers need a dependable and trusted source of information that provides useful guidance on treatment options available."

However, there might just be the teeniest bit of opposition out there even with AHIP’s enthusiasm (and the cynics would say because of it)….so don’t expect any one agency to have controls over exactly what care gets paid any time soon.

Most of this morning at the FIDMD meeting has been largely technical stuff about setting up decision aids. Shannon Brownlee suggests that the name should be changed to “personalized medicine” which has been nicked by the bio-tech crowd for now.

There is progress in better patient information around systematically including patient preferences, values & desires at the point of care—particularly in prostate screening & breast cancer. (Good programs at Dartmouth, the VA local UCSF, Group Health of Puget Sound, and several other primary care programs in academic medical centers).I won’t bore you with the technicality of the decision aid methodology (because I didn’t understand much of it!)

All good stuff and all leading to the question, what happens when this starts to get mainstreamed because, (of course) better informed patients tend to desire less aggressive care? (Although interestingly there were actually several anecdotes about cancer surgeons & radiologists now pushing lumpectomy on some women who actually want the radical masectomy—so even when “do less” becomes the mantra it may not fit what patients want). But overall, this is a threat to the ability of patients to entreprenurially do what they want and get paid for it.

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More from Matthew at the FIMDM conference

David Jones, Harvard medical historian on revascularization

Why do you need a randomized clinical trial (RCT)? From the 1960s surgeons could show that CABGs opened veins (removed plaque) so why was there a need?  As it turns out, it’s not the large plaque in the vein that kills you but instead it’s the smaller “fragile” plaque which ruptures & causes heart attacks—it’s not the big blockage that causes the heart attack. Angioplasty (PCI) doesn’t get that fragile plaque out, so it shouldn’t be used as much as it is. Of course that’s not what happened. We’d already been shown that by Lee Lucas that there was lots more angioplasty when this theory became well known

However in fact the theory about these fragile plaque rupture was in the obscure cardiology pathology literature in the 1960s but didn’t break through to the mainstream cardiologist opinion until the late 1990s.

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So Indu & I invite Alan Greene and Sarah Greene out to dinner in Utah few months ago. Alan is famed pediatrician from drgreene.com. Sarah runs the NY Times Health page. And now Alan has his own column on parenting on NY Times.com. And both their last names are Greene! A coincidence? I think not!

(Actually I think it’s great to have such innovation on the NYT, but this was too hard to resist!)

I was highly struck by something Dr David Sobel said in his great speech at the Ix Therapy conference last October—he suggested some 50% of primary care office visits are the result of background mental health issues. That sounds intuitively right. After all a British GP once told me that his most frequent symptom was “TATT” (tired all the time”).

Meanwhile I’ve been getting to know a homeless childrens’ organization in San Francisco, which specializes in mental health services for those families. And not surprisingly those kids have issues that result in wide social and health problems later on (but not too much later on) in life.

Then today a reader asked me if there was any evidence on whether more care overall, and specifically more specialty care, would help those with mental illnesses? And whether providing more treatment manages to save money down the line (presumably in other areas).

Mental health has not been an area we spend much time on at THCB, other than perhaps to acknowledge that we over-medicate some populations. But Vic Fuchs did say to me once, “remember, the head is connected to the body”.

So does anyone have any data or conclusions about whether specialty mental health care is a) effective and b) a good investment? Please comment below.

Looks like CNN’s Glenn Beck won’t say what his local hospital’s CEO would like to hear when Press-Ganey call him! He accuses the staff there of not caring.

At the hospital I was often treated more like a number than a patient. At times, staff members literally turned their back on my cries of pain and pleas for help. In one case a nurse even stood by tapping his fingers as if he was bored while my tiny wife struggled to lift me off a waiting room couch.

So far he hasn’t named names, but I suspect that when it gets out, it’ll be worse for the hospital than it having a bad overall mortality rating in some obscure state report. After all when Don Berwick and David Lawrence wrote about their wife and mother respectively, they went out of the way to praise the staff, while castigating the care system. Beck is not so kind.

I’m not sure Beck’s solution is too constructive.

That’s why I don’t want to hear anymore about universal health care or HMOs or the evils of insurance companies until each and every hospital in this country can look me in the eye and tell me that they their staff is full of truly compassionate people who treat their visitors like patients, not products. Hire and train the right people, and then and only then come talk to me about everything else you need.

But his complaints are echoed in a series of videos from Health care for All in Massachusetts which also start talking about problems with care quality. I wonder if Paul Levy will name names about the hospitals in the last two videos—Both prominent Boston teaching hospitals that both screwed up big time with medical errors

Final thought: perhaps Michael Millenson is finally influencing people….while he’s even still alive!