Cost of Health Care

Share | How cynical is it to have the economy supported by an industry that profits from and depends on the unhealthiness of our population?


Health spending reaches 3 trillion USD with rising drug costs and the general lassie fair commercialization health care. The 3 trillion amounts to $9,523 per person and a 5.3% increase over last year.
 Washington Post

Medical Education

It requires far more medical knowledge to practice quality medicine on the front lines of clinical medicine than ever it does in the specialties. The specialist's narrow focus limits competence in other specialties and the spaces in between. The education is all backwards, the primary care physicians need a more highly advanced more extended education. A six or seven year residency with a PhD in clinical medicine would serve nicely featuring a clinically relevant discipline such as genetics or epidemiology etc.

An abundance of exceedingly well trained family/personal physicians could solve most of today's problems, but large numbers of best qualified candidates could only be attracted if given a prestigious academic challenge with the rewards to match. The midevil medical school in Sarlrno, Italy 900 AD graduated medical students with a PhD, -- a just reward -- it could work today in leading medical schools and thereby attract the numbers and quality of primary care physicians needed to set the balance strait.

Physician extenders should receive much of the training family physicians get today, but never practice independently! The algorithms provided by specialty groups, burocratic planers, drug companies and best evidence can never accommodate the complexity and multiple problems inherent in the human condition: nutrition, environment, drugs, poverty and abuse. It will require a physician and a deep and shared relationship to grasp those problems and thus elevate the sad level of health that limits much of our population, our work force, our idle youth and many of our veterans. This unbalance, this distortion in our profession is worth fixing.

Hippocrates

Medicine today suffers almost as much from political intervention as ever it did from priests, shamans and religious dogma of the past. Reform, liberalism, and political correctness marginalize Hippocrates, the hippocratic method, and with him the sacred, ethical, humanitarian and scientific charactor of the profession.

Ideals of reform, political control, regulation, commercialization, political correctness and well intended lay ideals of social progress erode the authority, self regulation and ethics of the profession. Imagine lawyers without the standards and restraints of "The Bar."

Imagine doctors without the standards and restraint of peer review, held only to the gray areas of legality with profit, cynically, the only motive. The evolution of greed seems more and more evident at many levels. I fear that medical school reform proposes to adjust curriculum in order to accommodate this sad reality.

Take the now universal after hours sign off to 911. When did local medical societies decide that a doctor no longer needed to provide after hours availability for response to after hours emergencies or complications? I think in fact it was hospitals, not the medical society that made that change. Was there economic motive? You bet. Hospitals are now a multi billion dollar monopoly with legal sanction. For myself, I thank God for the VA and trust only the mainstream medical school.

On a historical level, medicine has suffered before and recovered; it will do so again. For the medical student, read Hippocrates, travel to some of the great medical schools abroad, be a humanitarian, a poet, a musician and always a scientist. Own a microscope. Do good works.

Quantum Biology

Richard P. Feynman in his published lectures, The Strange Theory of Light and Matter QED, wrote,

"The theory of quantum mechanics ... explained all kinds of details, such as why an oxygen atom combines with two hydreegen atoms to make water and so on. Quantum mechanics thus supplied the theory behind chemistry. So, fundementally theoretical chemistry is really physics."

The parallel in molecular biology is quite obvious. We deal with DNA at the molecular level. The next great step will be a theoretical explaination of molecular biology at the electron, photon and particle level, the level of quantum intanglement. Thus the theoretical understanding of molecular biology will also really be physics.

2,450 years ago Greek medicine was called physics. Aristotle had contemplated the existence of particles. The enquiry into how things worked, especially physiology was called physics and the stem of our word physician is indeed physics. With quantum biology we have come full circle.

23 and Me

23andMe posted a letter to its customers announcing that after two years of work they are now able to  share the wellness implications of their customers DNA directly to its customers. They promis a report by year end. 

The 23andMe database appears to be the biggest in the World and academic institutions are buying into the data for research. Furthermore, the vault of stored samples remains available for further research while the data remains anomonous with the individuals information remaining the property of the individual rather than some other institution or the government.

This becomes a breakthrough for clinical medicine, which heretofore faced a roadblock over confidentiality, the position of nearly all specialty groups and the assumption that the information would be too sensitive for the patient to have access to. Now, the clinician will have access to a patient history containing multiple SPN traits that are of preventive as well as diagnostic value, a great day for translational medicine.

Molecular Biology

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As we attempt to accept the data afforded by genomics, the greatest challenge to health remains nutrition and poverty. While the science accelerates the issues of fresh produce, healthy eating and poverty languish. Why is that?

Wrong Diagnosis

Share |Suprise, surprise, as medical schools scramble to introduce curriculum reform to keep pace with mediocrity, they eliminate the microscope, the doctor's personal lab, the autopsy, and in the name of confidentiality and privacy, bedside teaching is all but forgotten. Sub standard medical schools are a growth industry. Best evidence concentrates so on treatments that we have treatments in search of a diagnosis, particularly expensive highly profitable procedures or drugs. We teach with "standardized patients" a synanym for actors who can never teach the student the reality of a disease or its diagnosis. In our haste to produce alternative providers, we treat health care at the lowest denominator of competence. Any one with a stethescope around their neck is a provider. There are still true physicians, but they are fenw and far between. We still have great medical schools but they are under pressure to make the big bucks, to be self sustaining. Physicians today struggle with commercializations as renasance physicians struggled with the church.  

5 Disasters of the Afordable Care Act, Obama Care

1. It is indeed a tax, progressive fortunately, but inequitably so.

2. There is no provision for autopsy or a physician's own small laboratory, prohibited.

3. There are lots of provisions for providers without adequate medical school training.

4.  The Act allows drug companies to charge what ever they want and prohibits negotiation.

5  it encourages the recording of false or erroneously superfluous diagnosis.

What it has done is acknowledge the need for universal health care,but it needs to morph into a dual system private coverage competing with a universally available single payer system.

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Autopsy

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http://www.pbs.org/wgbh/pages/frontline/criminal-justice/post-mortem/without-autopsies-hospitals-bury-their-mistakes/

Four years later and autopsies remain the forgotten basis of scientific medicine. Headlines read, autopsy rates are falling, but they cannot fall from the near zero percent presently undertaken. Some new hospitals do not even provide examining space for autopsies. The NEJM publishes CPCs on living patients. A pity today's epidemic of curriculum reform does not include autopsies, a further sad accommodation to today's reality. Check the PBS link, it's well done.

The renaissance of modern medicine was lead by the microscope and the study of anatomy; it became clinical with the routine practice of autopsy by Marie Francois Bichat in Paris 1793, the stethescope, Rene' Laennec 1822 and the classical bedside teaching of the great Scottish and Irish physicians in the early 1800s. From Bichat, over the door to his autopsy room, "Death comes to the aid of the living." 

Cynically speaking -- we have all but legislated these practices out of existence, the autopsy for money, bedside teaching for privacy, basic science for curriculum reform with greater emphasis on preceptors and, ah the stethescope, it hangs around the neck in color coordinated pastel colors only to pretend to hear something through the patient's clothing. An anatomy professor recently commented, "They have a microscope down in Seattle under glass so students can see what one looks like."

Community Acquired Pneumunia

Share |NEJM reports a study of community acquired pneumonia comparing treatment with bata lactams, macrolide-beta lactams combination therapy or fluoroquinolone mono-therapy with mortality.

Why "community acquired pneumonia"? Hippocrates was more specific. By the very name we are excusing ourselves from the very art of clinical diagnosis that has taken centuries to develope. We have not replaced that art with PCR or fluorescent microscopy. The term community acquired pneumonia can only be an excuse for expedient treatment and disposition. I would wager that the stethoscope was applied over the shirt and the acknowlegment of community acquired pneumonia not made until the X-ray was positive. By then we might better call it late diagnosis of pneumonia of unknown etiology obscured by inappropriate antibiotic therapy.

Rene Lanec brought us the stethoscope, but we wear it around our neck, color coordinated as a fashion statement and we listen through clothing if at all. One should easily diagnose pneumonia before the X-ray is positive and with a bit of a history and a Gram stain narrow down the etiology and a culture before starting any antibiotic.

d-pneumo. Is the easiest to identify with a Gram stain and any strings of strep. clearly justify beta-lactams. Macrolides cover the hard to identify atypical pneumonia and the clumps of staph on the slide suggest a more resistant organism. Beta lactam macrolide in combination may still cover the possibility of atypical, but with the combination of a bacterialstatic with a bacterialsisal, the one may inhibit the effectiveness of the other. Then there is TB and pneumonocysticis - in more vulnerable patients. But what is community acquired pneumonia other than an excuse.

NEJM 2015,372: 1312-1323;  2 April. DOI 10.1056/NEJMoa1406330

Medical School Curruculum Change

Share | Curriculum change might better address the need for PhD level bio molecular medicine, autopsies, bedside teaching and send the standardized patients packing. Yes, 6 years of medical school, a PhD based on genomic research and clinical correlation. Enough said. Only the top schools will be able to pull this off. The harder you make it, the more will apply. In this day of poor moral, loss of respect and general indifference, the students with the capacity to become physicians and the surgeons of tomorrow will compete for the privilege.

Curriculum Reform

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When I hear medical school deans rushing to reform curriculum in order to adapt to the changes in medical practice they see coming, I fear for the unintended consequences. We don’t have a very good track record in health care reform. Nearly everything government has done to improve health care and reduce cost has had the opposite effect.

Yes, the insured fee for service system needs to change, but preparing our young doctors to work for a salary under institutional guidelines opens the flood gates for a limitless influx of unscrupulous health care entrepreneurs. The physician of tomorrow might better look to organized medicine, group practice and a leadership role healthcare design.

Instead of preparing medical students for electronic health records and best evidence algorithms, we should focus on genomics, proteomics, artificial intelligence and the humanities. (public-health poverty and nutrition)  Should we want to educate our young doctors as a feldsher[1] or as a scientist trained to lead us into the era of the genome?

I would hope that an evolution of the curriculum could focus on genomics, humanity and the underlying science of statistics and the computer. One might also consider extending medical school a year or two longer in order to explore the clinical applications of genomics and the related science, awarding a PhD for credible contributions in these applications. Doing so would give the young physician the credentials to lead the profession as well as patient care and community health.

The Civitas Hippocratica in Salerno, Italy 900 AD required 5 years of medical school. The graduate was awarded a ring, a laurel wreath, a book and a kiss. By 1158 UNIBO in Bologna, Italy required 6 years and until recent times awarded the PhD. Students were protected by law from all political and religious interference.[2] We should do so well.

Free enterprise has no place in medical practice; it has replaced compassion with greed. We sense this intuitively but the reasons are elusive. Politicians impose a lassie-fare philosophy with a religious fervor. Health care is not a free market, and with insurance there is no competition and no restraint; Insured fee for service effectively creates a monopoly subject only to a token proof of necessity. Our medical graduates need to stand tall and lead with overwhelming competence.

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[1] Feldscher (Gr.) a health care professional who provides various medical services in the Russian Federation and other countries of the former Soviet Union, mainly in rural areas.

[2] 1158 Frederick I Barbarossa promulgated a Constitutio Habita, establishing that every school be established as a "societas di socii" (group of students) overseen by a master (dominus) remunerated by the sums paid to him by the students. The Empire undertook to protect scholars travelling for the purpose of study from the intrusion of all political authorities

Peripheral Pulse

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Lifting the right wrist of the patient and palpating the pulse with your 3rd and 4th fingers is the handshake of the physical examination. Lost and forgotten or never learned, buried in the M1 text books, the peripheral pulse should be or is the physician's first encounter with his or her patient. The act of palpating the pulse, tells the physician much about the patient and the patient much about the doctor, opening and sharing the patient's and the physician's personal space in a mutually gentle and informative way.



Unfortunately, a false sense of economy and efficiency relegates this seemingly simple recording of figures to others, to the lowest level of  competence. This first level of diagnostic data must not, however, be trusted to others. The same might be said of the blood pressure cuff. Hidden diagnostic nuances are lurking there behind the numbers. 



The weak pulse with a slow uptake and a prolonged peak, easily  suggests decreased stroke volume, volume depletion, heart failure, aortic stenosis, hypothyroid or congestive heart failure. Whilst the bounding pulse with short peak and steep sides, suggests increased volume, decreased peripheral resistance, fever, hyperthyroid, anemia, bradycardia, aortic regurgitation, patient ducts, A-V fistula or hardening of the arteries with age. The start of your differential diagnosis and knowledge of your patient lies right beneath your fingers.



Some of your differential diagnosis might be missed entirely but for the thoughtful palpation of the peripheral pulse. Bisferiens Pulse with a double peak, may be due to aortic regurgitation or regurgitation combined with stenosis or even hypertrophic cardiomyopathy. Pulsus Alterans for example, a normal beat alternating in regular interval with a weaker beat (and an S3), suggests left ventricular failure. While Bigeminal Pulse, a normal beat alternating in shorter interval with a premature contraction of weaker strength, suggests retrograde conduction etc. Intriguingly, Paradoxical Pulse, wherein pulse pressure increases more than 10 mm Hg on expiration, can lead to the early diagnosis of an unsuspected constrictive pericarditis, even  tamponade or COPD. The later can be life altering for the patient and greatly enhance the career satisfaction for the physician as it did for me.
 

La Maladie du Petit Papier

Share Jean-Martin Charcot (1825-1893) at Salpetriere in Paris - a neurologist famous for the beautiful hospital, the Charcot Joint and Charcot Marie Tooth syndrome - may have initiated the term "La maladie du petit papier" observing the triviality and the seeming benefit derived by the patient. The term has become a derogatory one, however, expressing the irritation to the physician from the patient's attempt to organize his or her problems. Does not the phrase, la maladie du petit papier, uttered in contempt, give a false sense of superiority and sophistication, suggesting that one can actually say something in French? 

As Koven's Perspective letter in NEJM implies, there may be more to this. "...even when I have no explanation for the headache, upset stomach, or itch - documented on the back of an envelope or punched into a smart phone, a patient feels better just having presented me with his or her recording of it. Perhaps naming our demons and saying their names aloud helps make them less frightening. Perhaps the shorthand of the list somehow abbreviates the anxiety associated with its entries."

Is not the patient, indeed, attempting to build his or her own problem list? Charcot was one of the great physicians of all time, but there was a first - greater yet - Hippocrates, who founded the very science of listening to the patient, observing the environment and documenting the patient's complaints. I rather imagine that Hippocrates would have welcomed la petit papier.

Indeed, is not the petit papier the patient's own problem list? Why not capitalize on the benefit to the patient of reducing their complaints to a problem list - be sure to include them all - and combine them with a check list of past medical illnesses, review of systems etc.? If the problem list has a placating effect on the patient, think what it does for the physician to actually see at a glance the patient's entire struggle with his or her environment and maladies. A problem is not a diagnosis, more likely a symptom, but without the complete problem list, there is no way to know that you've got it right with either the diagnosis or the underlying causes.

Suzanne Koven, M.D. NEJM 2014; 371:2251-2253; 11 Dec; DOI: 10.1056/NEJMp 1411685

(POMR) Problen Oriented Medical Record

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While POMR heads the Syllabus for the teaching of medical history taking, most first year medical students encounter a source oriented format or at best a hybrid system without ever learning the problem oriented system, a system first promoted by Larry Weed at Dartmouth in the early sixties. In truth, the hybrid system of charting a patient's medical history and progress, may be superior in that, including the source oriented, or more traditional, style better identifies the full character of the patient as seen through the physician's eyes. Tradition since Hippocrates tells us that "if you just listen," the patient will tell you everything you need to know. The traditional chief complaint, history of the present illness, past medical history, social and family history followed by a complete review of systems constitutes the source oriented medical history. The medical history is a story, with color, pathos, complication, progression, humanity and hopefully, with your guidance, a resolution. It is a story worth telling and worth telling well. Both the patient and physician will likely evolve in so doing.
The POMR, however, represents a far better way to organize information when there are multiple problems. For instance, for an older patient who might have a dozen or more concurrent, problems, some undiagnosed, some controlled and some resolved, the problem list brings together all of the concurrent problems. The POMR lists the patient's problems as a table of contents, numbering each problem, dating the identification of the problem and dating its resolution. The two dates are critical in referencing the place in the progress notes where and by whomever the problem was identified and the strategy outlined in the SOAP note for diagnosing and treating the problem. 
POMR, furthermore, helps with diagnosis, listing all the problems in one place, exposing their potential relationships and synergisms, opening a window to greater understanding of one patient's struggle with disease and his or her environment. Problems get lost in the time constraints of employed providers. A positive response on the (ROS) review of systems is by definition a problem worthy of placement on the problem list, yet problems get dropped, lost, forgotten, never to be seen by subsequent team members. One could therefore argue that the problem list is the most important but often least understood page on the patient's chart.
The SOAP note then describes the subjective information derived from the patient as well as the intuitions of the physician in a stylized format followed by objective data, an assessment of the condition and finally a plan to move forward. Larry Weed, he's now in his 90s living in Vermont, insisted on including a rationale and the goals you expect to achieve.
Thus:
# - Problem
S: subjective
O: objective
A: assessment
P: plan
The POMR oriented patient history consists of a series of SOAP notes: indexed to the problem list, replacing the traditional Chief Complaint and Present Illness, written in numeric order and positioned at the beginning of the patient history. The rest of the traditional source oriented history may follow or in the case of the POMR purist, included in the initial numbered SOAP format in the initial patient history.
Daily progress notes then follow in the same SOAP note format rationalizing every laboratory test and medication order - this in sharp contrast to the typically thick hospital chart in which the orders written have little or no relationship to the progress note or indeed the problem for which the order was written. With multiple specialists dealing with one patient, the organizational advantages of the POMR seem obvious.
An individual physician's own hybrid version combining the POMR with the narrative of the traditional source oriented history promises the best of both worlds. However, the advent of  the (EHR) electronic health record, makes a very loose structure out of either the POMR or source oriented system. There may be no way to write a program that will accommodate all patients and all doctors. The POMR does, however, lend itself rather well to the structured format of the EHR, but only if it accommodates a narrative and tells the story in supporting either the source oriented or POMR system or indeed the hybrid which should be taught. Voice recognition would seem essential in allowing the story to be told quickly and in depth.
 Now more than ever, the so called medical home, teaching hospital or multispecialty clinic depends upon a high quality medical record to paint a true picture of the patient, the patient's environment, their problems and relationships in order to build a differential diagnosis or to explore the subtle underlying causalities.

 

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