Saturday, January 28, 2017

Demonetize Medicine

Fashions come and go. Medicine despite our scientific origins engages in the same, some internal some externally imposed. Capitalization and industrialization promised a health care system where in current industrial management technologies would lower cost, increase productivity and improve outcome. Corporations, mergers, and healthcare providers compet for space at the seemingly unlimited healthcare feeding trough. The art, compassion and excellence of an Aescelapian medical profession gave way to greed to put it bluntly. Industrial medicine monetized every aspect of healthcare raising prices to the point of deminishing returns at the bottom line, unbundling and championing a new class of supper administrators with salaries in the millions. As a result, US medicine, for a time, the  world's leading profession, now ranks near the bottom of the 37 countries comprising the Organization for Economic Cooperation and Developement (OECD) and their metrics for ranking health care. We have the highest underlying cost structure, the most obscene prices and the worst outcomes, reference the Global Burden of Disease (GBD).

We are in the midst of replacing a structure who's heart was in the right place but still did not cover everyone, was a fiat progressive tax system to itself and had the effect of a blank check for procedures, Perscription drugs, hospitals and any other organization with a pretext of healthcare. Politics, burocracy and external forces rather than professional, medical and academic drive the change as well as the outcry to maintain the status quo.

Disruptive change in the form of genomics, artificial Inteligence, imminaging and hand held or bedside diagnostic tools in the hands of the primary care physician may demonetize much of the burden. However, there remains the challenge of removing layer upon layer of administrative waste, a system of corporate medicine favoring the bottom line over patient care we need a return to basic education, excellence and especially continuing medical education (CME).

If I was the Zar, I would run a public system through medical schools, state by state, open to everyone, salaries only with incentives, and run it in competition with private insurance based fee for service. We are playing catchup, so there is nothing wrong with looking at European systems that produce better outcomes at much lower cost. Demonetize the greed.

Saturday, January 7, 2017

Stethescope, a Lost Art


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February is the 235th birthday of Rene' Laennec, the French physician who in 1816 attempting to listen more carefully to the chest of a young woman suffering heart disease and unable to place his ear on her chest due to her sex and obesity, ruled up the paper chart to listen through the tube. The acoustics worked so well that Laennec developed a wooden tube for routine use.

Laennec was born February 17th 1781 in Brittany. His mother died of TB when he was 5. At age 12 he studied medicine with an uncle at the University in Nantes. A good student, Rene' wrote poetry, learned English, German, studied Greek, Later in 1799 at the University of Pari, Laennec reintroduced the art of percussion as described earlier, 1761, by Leopold Auenberger, a cellist, physician and friend of Motzart. In 1816 Laennec developed his acoustic tube and explored its further subtelities for diagnosis. Laennec published his classic text De Auscultation Mediate 1819, a notable reference even today. Laennec worked as a chest physician, lecturer and professor at the College de France 1822-23; he treated TB patients at the Hospital de la Charite'.

Laennec was said to have had TB, possibly since childhood; he died in 1826, at age 45, having made one of the greatest contributions to the art of medicine -- the same year Chopin published his Polonaise in London.

Tuesday, January 3, 2017

Brain Mets or Psych?

An advanced cancer patient refusing treatment, presents all sorts of problems for family and providers. Compound this with bizarre psychiatric symptoms and contrary behavior and you have legal and ethical challenges as well. The first thing one does is order a psych consult, a tenuous diagnosis, even commitment, in the extreme, restraints. This Perspective Articlre in NEJM describes such a dilemma. Dec 8 375 2220-2221 DOI 10.1056/NEJp 1612129

My first rotation as a junior medical student -- UMichMed '60 in "Old Main," a 2000 bed hospital with 20 bed wards -- was "Blue Female" 2nd floor east, exclusively advanced breast cancer. Each ward had its own personality, largely driven by the nursing staff and the patients themselves. Blue. Female's was one of mutual support and suprising spirit; they shared in one another's condition, complications, prognosis and listened through the curtains to one another's daily rounds. Despite turnover and a frequent empty bed, you could feel the strength and moral.

Not infrequently, however one or two would become recalcitrant, atgumentive and display bizarre ideation. Residents and young professors, new to Blue Female, would invariably order a psych consult and speculate over which psych diagnosis. We did not have MRI, but everyone in the ward knew the problem was metastice to brain, even the ward clerk who did not rotate. We did not need an MRI or for that matter a psychiatrist who usually failed to figure it out.

Not long ago, I listened to an ethicist presentation of an almost identical case to the one in the NEJ. The case involved court orders for treatment and, early on, a court ordered confinement for psychiatric care and family guilt. No one thought to order an MRI.

Sadly we have losst the beauty of bedside teaching, supportive wards when support is needed the most and that's not to mention autopsy which would indeed figure it out, without the family having to say, she went crazy in the end.