Categories

Tag: Saurabh Jha

Saving Normal

Screen Shot 2015-12-16 at 1.39.02 PMThe iconoclastic psychiatrist Thomas Szasz said that mental illness was metaphorical, not real, because mental diseases lacked biological substrates. The absence of a substrate predisposes psychiatry to overdiagnosis and avoiding overdiagnosis is psychiatry’s biggest challenge. This challenge has been taken up by Allen Frances in Saving Normal. Like Szasz, Frances writes in cultured, erudite prose. Unlike Szasz, Frances believes that psychiatric illnesses are real. To save the mentally ill, to save psychiatry from itself, Frances says we must save normal.

Six years ago, Frances was enjoying retirement after a distinguished career, minding his business sipping cocktails at the annual meeting of the American Psychiatric Association (APA). Psychiatrists were excited about updating the Diagnostic and Statistical Manual of Mental Disorders (the soon to be DSM-V). Frances had chaired the previous edition of DSM, but in the zeal of the latest edition, he saw diagnostic hyperinflation of a frightening scale.

Continue reading…

The End of the NHS?

Screen Shot 2015-10-30 at 3.13.19 PM

Britain’s health secretary wants to uncharm his way to a revolution.

To galvanize support for a seven-day National Health Service (NHS), which the NHS was before Jeremy Hunt’s radical plans, and still is, he asserted that thousands die because there is a shortage of senior doctors during weekends. This is an expedient interpretation of a study which showed that mortality was higher in patients admitted on weekends. Hunt ignored the fact that patients admitted on Friday night are actually sicker than those admitted on Wednesday morning.

When logos failed, and after briefly dabbling with pathos, Hunt resorted to ethos. He insinuated that doctors were clock watchers (“service that cranks up on a Monday morning and starts to wind down after lunch on a Friday”). This led to a hashtag on Twitter: #ImInWorkJeremy.

Hunt wants to modernize the NHS. Leaving aside whether modernization is modernization, post-modernization or pre-post-pre-modernization, presumably this endeavor benefits from having doctors on board. How has Hunt enticed the doctors? He prophesized that GP’s diagnostic skills could be obsolete in twenty years. He wanted to replace doctor’s clinical judgment with computers, sooner rather than later (he’d just returned from Silicon Valley).

Continue reading…

Right Care Action Week – What can Radiologists do?

thcbThe Lown Institute advocates rational use of medical resources. This is a noble goal and worthy of the attention of radiologists. This week is the right care action week. Here are five simple things any radiologist can do this week, and the following weeks. This will improve patient care by avoiding unnecessary tests.

    Speak to the referring clinician, at least sometimes, if not often, perhaps twice a day. The conversation need not be adversarial. Ask before the imaging two simple questions. What will you do if the test is positive? What will you do if the test is negative? Inquire four weeks after the imaging is done if the study changed the clinical management. Inquire politely displaying academic curiosity not, judgmentalism. Appropriate use is a two-way street.

Don’t call pulmonary hypertension if the main pulmonary artery is > 3.1 cm on CT. Yes, I know this is the threshold, but thresholds are arbitrary. The chances that you will pick up pulmonary hypertension incidentally in someone with a 3.2 cm main pulmonary artery are dwarfed by the chances of an unnecessary right heart catheterization to confirm that the pulmonary hypertension was never there. It’s not fun having a right heart catheterization, even though cardiologists are really nice people.

Follow the ACR guidelines on the management of incidental thyroid nodules. Remember, if you pick up a papillary carcinoma of the thyroid, chances are that this will be overdiagnosed. Just ask the South Koreans. Be daring and bury the nodule in the “body” of the report, not the “Impression.”

Don’t leave the decision to following an incidental adrenal nodule, which is over whelmingly likely to be benign, on CT in an eighty year old to the referring clinician by saying “MRI may be obtained if clinically indicated.” Take ownership of the decision. Do we really believe that net societal suffering is reduced by doing chemical shift MRI on adrenal nodules on octogenarians? We are simply diverting their limited time on this planet from their grandchildren to the magnet.

God invented radiologists so that he could not be ruled out. The hedge is important, on occasion. The hedge cannot be a way of life. Please stop saying “sub segmental pulmonary embolism cannot be excluded.” Sub segmental pulmonary embolismis often an overdiagnosis. Let’s save our hedges for real monsters. On a similar note, just say “normal.”

 Radiologists can reduce societal burden of too much medicine. We know the Axis of Futility, by heart.

Saurabh Jha is skeptical by nature not because he hates you. He can be reached on Twitter @RogueRad

What India’s Teleradiology Market Teaches Us About the Future of Medicine

Teleradiology has the same effect on radiologists as Lord Voldemort has on Muggles. It’s the feared end point of the commoditization of imaging, with Rajeev in Bangalore outpricing Rajeev in Chicago for reading follow-up CTs for lung nodules.

But despite the fears of U.S. radiologists, their counterparts in India have more pressing things on their mind.

“U.S. radiologists think that Indian radiologists are [itching] to steal their jobs. We have plenty of work in India,” reassured Dr. Sumer Sethi, director of TeleRad Providers of New Delhi.

A tech-savvy blogger, Sethi founded TeleRad Providers in a flash of inspiration and an appreciation of market forces.

“There is unimaginable competition in private medical imaging in New Delhi,” he said.

A new radiologist wishing to set up shop in one of India’s metropolitan areas faces large upfront costs: There is little discount for a 1.5-tesla MRI scanner. This means one must have abundant spare change floating around — or ancestral wealth. And once the shop is set up, the aspiring radiology entrepreneur embarks on a long and uncertain road toward establishing reputation and market share.

Employment models in the U.S., such as partnership tracks and buying into a practice, are not generally available to Indian radiologists. The alternative to entrepreneurship is working as a salaried employee for a corporate hospital, private imaging center, or government hospital. That was not the career pathway for Sethi, whose teleradiology practice is a pure fee-for-service model.

“It’s a low-cost operation,” he explained. “We read from home.”

An elegant model

The costs of an Indian teleradiologist are certainly low. Sethi does not have to deal with intermediary agents. There are no concerns about using the wrong billing code, and there are no separate state licenses to acquire. The model is elegant in its simplicity. He gets a study, renders a report, and gets paid.

However, the low operating costs belie the actual effort that is required of Sethi to grow his practice. He negotiates with hospitals directly. Being an entrepreneur means recognizing the need for teleradiology, and persuading others of the need and its solution.

Most of Sethi’s clients are hospitals in tier 2 and tier 3 cities in India, the equivalent of Dayton, OH. The hospitals have the machines and patients but not always the radiologists.

“We mostly plug the gaps in the rota at these places,” Sethi said.

This must mean that the radiologists at these centers welcome his efforts, I surmised.

“The scrutiny of our reports is intense,” he said. “This does not mean all our reports are overread. But were we to miss something, we could lose the contract, as the local radiologists would say, ‘See, this is a report from a teleradiologist.’ I tell my team that we must be at the top of our game, always.”

Continue reading…

Satisfaction Scores: How I Almost Made a Hotel Manager Lose His Job

Recently, I was asked to fill a questionnaire during check-out at a hotel in India. I was very pleased with my stay so I agreed to providing feedback. It is worth pointing out that if I was only mildly satisfied I would not have agreed. If I was disappointed with my stay I would have filled the form more enthusiastically.

When I offer feedback I am in one of two extreme emotions: I either love the service or, more commonly, loathe it. There is no time to talk about the average. And I have given up on Comcast.

The form had about twenty questions asking how satisfied I was with various components of their hospitality. I had to choose between one and ten, the higher number for greater satisfaction. I decided to set a record for the fastest completion of the questionnaire. I quickly chose ‘9’ and ‘10’. To appear objective I gave a ‘7’ to a service, randomly. Seven meant “above average”. Nine and ten meant “outstanding” – that is satisfaction cannot be measurably higher.

In the section which asked “how can we do better?” I said “put some more trees.” I didn’t really think the hotel premise needed more trees, but I was on a roll of objectivity. I had to say something.

Continue reading…

Doctor Paul Revere Fails to Light the Fire

Paul Revere
Writing in the Wall Street Journal (WSJ) Dr. Daniel F. Craviotto Jr. an orthopedist, made a plea to physicians to declare independence from third parties and emancipate themselves from servitude to payers, mandates and electronic health records (EHR).

As rants go, this was a first class rant. But its effect was that of a Charles de Gaulle’s whisper to Vichy France rather than a Churchillian oratory at the finest hour.

The article went viral (it has been tweeted nearly 3000 times), though with little virulence. And it is not WSJ’s paywall to blame.

The author might have assumed that most the healthcare community in general and physicians in particular wish to be free from regulations. I have serious doubts that this assumption is correct in the aggregate. The relationship between regulators and physicians is more complex and symbiotic than it first appears.

Some physicians believe in bureaucracy. Rationalism will march us out of our healthcare wilderness. This belief in scientific managerialism, faith in technocracy, is the new theism. The rationale of the new theists is that regulations fail not because they are inherently useless but because there are so few of them, and even fewer that are actually smart.

Like the first religions started with polytheism, the new believers want more agencies, more alphabet soups, more gods.

Continue reading…

It’s Raining Cataracts, Hallelujah

flying cadeuciiCMS released new data, shrouded thus far in needless secrecy: how much it pays individual physicians.

Unlike the Shroud of Turin, no one will question its authenticity. But authenticity doesn’t guarantee the data won’t intrigue, confuse, anger, perplex, confound and burn a few innocents at the stakes. That is before we conclude that more research is needed, or more colloquially stated, we still don’t have a clue.

Medicare bounty hunters, the modern day witch finders, are licking their lips for their share of the looted spoils. Academic researchers will be dissecting both wings of the bell-shaped curve of variation in payment to set the next battle between good and evil. But all eyes (pun intended) are upon Florida; specifically one particular provider.

The provider, an ophthalmologist, (you can look up the name) billed CMS for $21 million.

CMS paid ophthalmologists $ 5.6 billion. That’s more than the GDP of Burundi. CMS paid over a billion dollars for treatment of macular degeneration with Lucentis (Genentech).

Take a deep breath now. The treatment of one organ in over 65 year old American citizens is equal to the GDP of one African nation. Gini would have turned beetroot with embarrassment.

Diabolical? Scandalous? Shocking? Surprising?

None of the above, actually. If you think about it.

As we age, and age we do thanks to our lives being constantly “saved” by prevention, regulation and cures, arteries harden, brain atrophies and bones thin. And eyesight falters. Lens fog. Macula degenerates, reducing central vision making it difficult to read.

As we age, we consume more medical services. Yes, take that as an economic truism. And no, I’m not applying for membership of the Death Panel.

Here’s the thing. It’s nice to be able to see when you’re 75. It’s also nice to see when 85, and damn essential when 90.

Otherwise you might trip over the walking stick, fracture the neck of the femur, develop a clot in the deep veins, then a clot in the pulmonary arteries, then a raging pneumonia in ICU, followed by septic shock and a cardiac arrest. Then perhaps you may rest in peace. But not before a few interns have fractured half a dozen ribs during a well-intentioned but hopelessly misguided cardiopulmonary resuscitation that family members lobbied for to assuage their guilt for never visiting you in your nursing home.

Continue reading…

The Note Taker’s Dilemma

The year is 2020, or sometime in the future when the healthcare system is better, much better. Patients have access to their medical notes, are encouraged to read the notes regularly and ask physicians relevant questions. This is to facilitate patient-centered participatory medicine (PCPM), previously known as shared decision making. In fact, note reading by patients is now a quality metric for CMS.

The CEO of the Cheesecake Hospital Conglomeration, one of the hospital oligopolies, has set up a Bureau for Transparency and Protection of Patients from Complex Medical Terminology. The goal is to risk manage troublesome medical writing that could result in poor satisfaction scores, complaint or a lawsuit.

Mr. Upright (MU) is the Inquisitor General for the bureau. He has called the author (SJ), a repeat offender, to his office to discuss elements of his medical record keeping.

Disclaimer: Any resemblance to future events is purely coincidental. The narration is merely a reflection of the author’s paranoid affect and a tendency to believe in conspiracy theories.

MU: Dr. Jha, you’ve been summoned because your open medical notes do not meet the standards for empathy and compassionate care and seem devoid of a reflection on the complex interplay between social determinants of health.

SJ: Has a patient complained?

MU: No. But that’s what the bureau is trying to prevent. We protect patients from physicians. Actually, we protect physicians from their most dangerous enemy: themselves.

Continue reading…

Mixing Politics and Science Is Injurious to Public Health

If Obama’s nominee for the position of Surgeon General, Vivek Murthy, is not endorsed by the Senate because Senate Democrats from conservative states are too scared to vote for him for fear of losing votes from a population, egged on by the National Rifle Association (NRA), that passionately supports firearms, the first words that come to mind are ‘unfortunate,’ ‘tragic’ and ‘daft,’ although not in that particular order.

Words that do not come to mind are ‘surprising’ or ‘unprecedented.’  This is the natural result of decades of actively encouraging science to mix with politics.

In an ideal world, or I should say reasonable world, noting that perfection is not a pre-requisite to being reasonable, it would scant matter what Murthy thought about firearms.

He would be judged on his (impeccable) credentials, (unmistakable) leadership, and (imaginative) entrepreneurship not to mention his gumption in standing up for what he believes.

It would, of course, be utterly naïve to believe that in the real world his politics do not matter.

I doubt Murthy would have advanced so precociously, let alone been nominated for the position of Surgeon General, if he were a second amendment absolutist, an implacable limited government advocate or had written extensively about the role of free market in healthcare, all things else being equal.

We applaud him for standing up for his convictions not just because of his standing up but for the nature of his convictions.

This is not to suggest that Murthy’s worldview is expedient. There’s no reason to doubt its sincerity. It’s to suggest that a certain weltanschauung is incompatible with progress in academia and beyond.

That’s because despite living in an age of unprecedented reason we have been unable to render unto science what is unto science and render unto politics what is unto politics, a distinction our species has made little progress in making in the last two thousand years.

Continue reading…

In Defense of the Defense of Mammograms

To the two certainties of life, death and taxes, add another two: mammograms and controversy surrounding mammograms.

The Canadian National Breast Screening Study (CNBSS) has reported results of its long term follow-up in the BMJ: no survival benefit of screening mammograms.

To paraphrase Yogi Berra “it’s mammography all over again.”

Is the science settled then?

No.

Before I wade further it’s important to understand what is implied by “settling the science.”

Einstein said “no amount of experimentation can prove me right; a single experiment can prove me wrong.”In physical sciences a theory need only be disproven once for it to be cast aside. Heliocentricity cannot coexist with Ptolemy’s universe. The statement “all swans are white” is disproven by a single black swan.

What do we do with the studies that showed survival benefit of screening mammograms? Why does the CNBSS not close the debate over mammograms, like Galileo did with celestial egocentricity?

The simple and simplistic answer is because there are powerful advocacy groups, special interests; the pink-industrial complex who have a vested interest in undermining the science.

But that lends to conspiratorial thinking. Special interests cannot undermine Maxwell’s equations or Faraday’s laws just because they do not like them.

The testability of Maxwell’s equations is inherently different from verifying that screening mammograms increase life expectancy. We must acknowledge two types of science; the former, physical science, a hard science; the latter, a hybrid of biology and epidemiology, soft science.

Soft science is a misnomer. There is nothing soft about performing a randomized controlled trial (RCT), the methodological gold standard; in ensuring factors that falsely augment or attenuate impact of screening mammograms are evenly distributed, data reliably collected, cause of death accurately recorded and correctly inferred. But the human factor and all its inevitable foibles are unavoidable in soft sciences.

Continue reading…

Registration

Forgotten Password?