By BENJAMIN MAZER, MD

Doctors can be two-faced. This isn’t necessarily a negative attribute. Doctors have distinct personas for our patients and our colleagues. With patients, doctors strive for a compassionate but authoritative role. However, with each other, doctors often reveal a different demeanor: thoughtful and collaborative, but also opinionated and even sometimes petty. These conflicts are often the result of our struggle with evidence-based medicine. The modern practice of evidence-based medicine is more than the scientific studies we read in journals. Medicine doesn’t just change in rational, data-driven increments. Evidence-based medicine is a dialectic, a conversation. Doctors are being continually challenged to reconcile personal experience, professional judgment, and scientific data. Conflict can naturally result.

This struggle has been ongoing since the rise of evidence-based medicine decades ago. There are factions in medicine who are skeptical of clinical trials as the answer to all of medicine’s important questions, while other factions are wary of authority and consensus-driven medicine. These battles have traditionally been confined to the doctor’s lounge, both literal and in the figurative “safe spaces” of academic journals and conferences. But now the doctor’s lounge is going public. Social media is enabling doctors to rapidly communicate with each other. The heated public arguments that often result are in turn raising new questions about the effect of public discourse on the medical profession and the patients we serve.

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By KIP SULLIVAN

Lawton Burns and Mark Pauly, economists at the Wharton School, just published an article that should be required reading for all policy makers and health services researchers. The article,  entitled “Transformation of the health care industry: Curb your enthusiasm,” appears in the latest edition of the Milbank Quarterly.

Burns and Pauly undertook an enormous task and executed it well. They first sought to explain the assumptions underlying Managed Care (MC) 2.0 – the proposals promoted by the managed care movement in the wake of the HMO backlash of the late 1990s. Then they evaluated the probability that the MC 2.0 proposals will work as advertised. To do that, they looked at the relevant research and then at the social conditions that are impeding the implementation of those proposals. That’s a lot to bite off.

This is an unusually valuable article because of its scope, organization, and documentation. I will summarize it first, then discuss it in more detail. I’ll close with a discussion of my one serious criticism of this excellent paper: The authors, having made it clear they think the current “value-based” approach to cost containment is doomed, profess to see no solutions to rising health care costs.

Testing a mantra

Burns and Pauly are among the small minority of health services researchers who seem to be curious about the powerful norms that influence their profession but which are rarely acknowledged and never studied. They do not come right out and say, “Our profession resembles a religion more than a scientific discipline,” but you get the feeling they might agree with that statement if you could talk to them over coffee. They communicate their interest in the undiscussed norms both in the way they treat health policy jargon (they view it with some skepticism) and in their willingness to declare that fundamental assumptions underlying MC 2.0 were never tested.

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By NYU SPORTS & SOCIETY

Should young athletes be allowed to play tackle football?

Are concussions and chronic traumatic encephalopathy (CTE) a public health problem or merely one associated with professional sports?

Join experts in science, media, policy and administration at New York University, Wednesday April 18th, as they discuss whether our current understanding of head injuries and their pathology require immediate public action.

Register Here

Scientific Panel

Does the science support recent legislative efforts to ban youth tackle football for athletes under age 12?

Experts will present the current understanding of head impacts in youth sports and discuss whether bans on youth contact sports are justified and to what extent.

• Chris Nowinski, PhD, Concussion Legacy Foundation
• John Crary, MD, PhD, The Mount Sinai Hospital
• Mark Herceg, PhD, Gaylord Specialty Healthcare
• Jason Chung, Esq, NYU Sports and Society

Moderator: Arthur Caplan, NYU Langone Division of Medical Ethics

Media Panel

The role of mass media in driving public health issues cannot be overstated.  But when discussing head injuries, has the media fueled awareness or hype?

Leading journalists will provide insight on the process of reporting on head injuries and CTE.

• Alan Schwarz, formerly of the New York Times
• Daniel Engber, Slate
• Dom Cosentino, Deadspin
• Jon Frankel, Real Sports

Moderator: Cameron Myler, NYU Tisch Global Sports Institute

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BY VA WEST HAVEN COE CLINIC

If it weren’t for the round, scaly patch on the young woman’s shoulder, her doctor might never have known that she served in the Navy for 6 years. He wouldn’t have learned about her sun exposure during a year-long station in east Africa, where temperatures regularly reached over 100°F. But because he didn’t ask about her military history, he didn’t hear about the burn pits and dust storms that filled her lungs with toxic particles. He didn’t hear about the infectious diseases to which she was exposed. He didn’t hear about whether or not she was exposed to combat, or if she experienced military sexual trauma. Perhaps if she were an older man with fading tattoos and a Marine Corps baseball cap, he might have thought to ask.

Or perhaps not.

It takes a remarkable amount of courage for an individual to choose to serve in the military. Their time in the service unquestionably impacts their worldview and every other aspect of their lives. Their health and well-being are no exceptions. That is why all health care providers should know how to ask their patients about their military experiences. More veterans receive healthcare outside the Veterans Affairs (VA) healthcare system than within it, and that number is surely to grow if the VA is privatized, as recently proposed. The time is now for healthcare providers to educate themselves about taking a military history. As physician and nurse practitioner resident trainees, we ask these questions as part of our routine screening both inside and outside the VA healthcare system. The patient who was just described was one of us, and the answers to these questions play a large part in how our patients are diagnosed, treated and understood as people.

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By NIRAN AL-AGBA, MD

When Amazon, Berkshire Hathaway, and JP Morgan (AmBerGan) announced their healthcare partnership, Berkshire CEO Warren Buffett declared “the ballooning costs of healthcare act as a hungry tapeworm on the American economy.”  He is right. Our broken system is infested with tapeworms. Tapeworms are parasites; they exploit their hosts, drain resources, and suck the life out of their prey. Unfortunately, Buffet failed to call attention to the tapeworms specifically –they are insurers, hospital conglomerates, pharmaceutical companies, and pharmacy benefit managers.

As healthcare costs continue to skyrocket, Americans increasingly find themselves struggling to make ends meet. Direct Primary Care (DPC) is a tapeworm-free medical concept whereby: 1) a periodic fee is charged for comprehensive primary care services, (2) the arrangement is free from billing through third parties, and (3) if additional fees are charged, those are less than the monthly fee.  Depending on age, fees range between $60-150 per month. Patients gain direct access to their physician coupled with unprecedented levels of affordability.

DPC physicians provide protracted office visits, after-hours appointments for emergencies, and occasionally, even home visits. DPC practices can dispense chronic medications at wholesale prices, perform basic procedures in-office, and when outside testing is necessary, these physicians can negotiate discounted “cash” prices on behalf of their patients.  This model goes a long way toward restoring the sacred relationship between a patient and their physician. It is no wonder patients are leaving the health care system in droves.

The last obstacle facing expansion of the DPC practice model is their misclassification as an “insurance” product rather than a “healthcare” entity. Legislation, known as the Primary Care Enhancement Act, already exists to repair this mistake and has 29 cosponsors. H.R. 365/ S.R.1358 would allow for two things: 1. Taxpayers participating in a DPC arrangement may qualify for an HSA plan and 2. HSA funds could be used for monthly fees for a DPC arrangement. According to the Moran Company, this legislation is nearly “deficit neutral.”Continue reading…

Jessica DaMassa asks me about money in (Livongo) money out (Theranos), and how much is enough money for challenges (AMA & Google); all in this episode of #healthin2point 00–now on its own Youtube channel. Look for the weird 30 second extreme psoriasis I get in this video!–Matthew Holt