Sunday, March 31, 2013

Best Evidence, `for whom the bell tolls`


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Best evidence begs a number of questions: How do you define best? Best for whom?  Whose evidence? To whom does it apply? Where geographically and environmentally does it apply? Any slogan applied often enough and long enough becomes a cliché.  `Best evidence` applies to treatment, not to diagnosis. Without the right diagnosis, best evidence for treatment would seem irrelevant. That, however, is not the way we practice medicine today. Speed is everything. Diagnosis comes secondary to treatment, to the specialty at hand and secondary to the CMS requirement for tests and procedures – even for insurance reimbursement. Sorry, but the delivery of healthcare in the average hospital clinical complex has become more of a business than an application of the art, the science and the humanity of medicine.` Best evidence` runs the risk of becoming a tool for achieving the highest economic return for drug companies, insurance companies and hospitals. `Best evidence` can become a tool for subordinating the provider to administrative requirements, rather than limiting over treatment or the mistreatment for which it is intended.

For example: A 76yo WM retired truck driver seeks advice from a seemingly competent clinician in a large healthcare complex about his recurring bronchitis sometimes leading to pneumonia. He presently has only some loose rhonchi on physical exam, but does have a history of hay fever as a child and a smoking history of 20 pack-a-day-years, having stopped when he was 54. The clinician, limited for time, listens to the chest through his shirt, observes that the machine BP was normal taken by an aid, notes that the immunization history is out of date and that the patient has not had a colonoscopy. The provider dutifully fills in the check marks on the hand-held computer-record ordering a colonoscopy, immunizations, a video for smoking cessation and a TB skin test. The patient indicates that he has had BCG and has a mildly positive reaction. The provider then deletes the TB skin test and orders a CAT scan of the chest. The patient asks for something to stop the recurrent infections. The clinician then explains briefly and adds a video about misuse of antibiotics and the development of resistant strains. The CAT scan comes back questionable for a suspicious mass near the mediastinum. A repeat CAT is ordered for a month later. The repeat shows no change, maybe a bit better. Colonoscopy was negative; immunizations are updated.  All of the boxes on the electronic health record are checked appropriately fulfilling all of the tenants of `best evidence.` The clinician updates the problem list and expresses the opinion that it may be an old TB walled off in a lymph node requiring no further action, come back in a year. The patient ended up in the emergency room a month later with pneumonia.
Now in truth, the patient does have elevated blood pressure and a chronic allergic bronchitis together with aspiration, which has lead to recurrent bouts of debilitating bronchitis and pneumonia --- in this case, an emergency department admission a month later. A PCR for tuberculosis taken later as a requirement for a government job was negative for TB.

Later still, a kindly old internist practicing from his home does a complete history, system review and physical on our patient. He notes a Grade I murmur of aortic insufficiency at the cardiac base, indeed rhonchi and some wheezing in both lung fields, and an elevated BP. The physician places his patient on Lisinopril and defying the video’s newfound wisdom, adds prophylactic penicillin. The physician further steps outside of guidelines ordering basic lab including renal. His expectations of negative results are confirmed. A Holter monitor shows good BP control. A cardiac eco-scan shows good output. The internist asks the patient to return in one month for follow-up.
Not so exceptionally, this case illustrates a contrast between the urge to standardize care and the traditional physician driven care of the past. This is an actual case with some modifications for simplicity. If you were to view the regimented care as promoted by `best evidence`  from a cost basis or from an outcome basis, the kindly old internist wins every time. Why is that, when we know so much more today than we did and science is so advanced? Well, that is just the point. Science is advancing so fast that any standardized protocol becomes obsolete before it is printed. Furthermore, it applies to an arbitrary population not to an individual patient. It applies to an environment and location unrelated to the case at hand. Best evidence guidelines have the potential to serve the author of the guidelines rather than the patient for which they are intended. For example: a drug company for use of its patented high margin product, a hospital for its utilization of high priced procedures, an insurance company for its higher volume or a clinic for limiting its liability or the government attempting to  limit the cost of care -- all at the expense of the patient. Even more specifically `best evidence` may not apply to your patients own individual genetic makeup and his or her own proclivity for disease or reaction to treatment. Lastly, no treatment guideline can be valid in the face of missed or wrong diagnosis.

 

 

 

Monday, March 11, 2013

Autopsies


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


"A half-century ago, an autopsy would have been routine. Autopsies, sometimes called the ultimate medical audit, were an integral part of American health care, performed on roughly half of all patients who died in hospitals. Today, data from the Centers for Disease Control and Prevention show, they are conducted on about 5 percent of such patients." Frontline and ProPublica, Marshall Allen 12/15/2011
A number of factors contributed to inadequate diagnosis and to the declining ranking of American Medicine internationally -- not the least of which was the abandonment of hospital autopsies. 
Marie Francois Bichat (1771-1802) Paris, over the door to his pathology lab, Bichat wrote, "Death Comes to the Aid of the Living." 
The insurance does't pay. The hospital doesn't want it. Relatives are reluctant. The providers are afraid of liability, but X-ray conference and excessive use of the CAT scan does not come close to replacing the autopsy. Many diagnosis can only be confirmed or established at autopsy. It is the only way to conduct a meaningful CPC. Furthermore, there is no way to program a computer to offer decision support without confirming the data.  Insurance, Medicare and the Joint Commission should demand it and stop pussy footing around quality, missed diagnosis, and bad outcomes. Historically the autopsy represented one of the greatest breakthroughs in the advancement on medical knowledge.Asking for it was a challenge. That was my job as an intern. Hospitals were ranked by their autopsy rate so the pressure was on. If we could achieve consensus, we might require authorization for autopsy as a requirement for admission and regain some of our lost sense of academic excellence.

Friday, March 1, 2013

Radiation in Space Tourism (public)


On February 27, 2013, the Inspiration Mars Foundation held a press conference in the National Press Club to announce the plan of the foundation to launch a mission to Mars in 2018. Philanthropist Dennis Tito is going to totally fund the foundation ($100 million) initially. Tito voiced his intention to send a flight to Mars on January 5, 2018 when Mars moves close to Earth in favorable alignment. Stating that the technology is already in place and that the issues that need to be overcome are only the requirements of a 72 week trip. He acknowledges the psychological and physical challenges for the humans involved, but with perhaps an underestimation of the radiation issue.
 
Technology may not be the number one obstacle to a safe flight to Mars. The cosmic radiation along the way may exceed the level of human tolerance. Looking beyond Mars and our Solar System, the deleterious challenges of radiation and the limitations of shielding will be even greater. Avoiding the radiation, shielding or engineering humans to withstand radiation offer the only alternatives. The first choice of avoiding the radiation may prove the only safe one.

A version of “Avatar” the movie, may offer the only presently feasible way for humans to live in the cosmos beyond. Aside from the movie, we are making rapid strides along these lines with Drones and other robotic applications. Soon we may launch unmanned fighter planes. Think of experiencing a visit to a distant planet or solar system in virtual reality while controlling the vision, hearing and movement of a life like robot.

Lag-time will be an obstacle. Quantum entanglement and the quantum computer may resolve that issue. The traveler might live in a lifelike replica of the space vehicle and operate a control module not unlike the Da Vinci surgical robot. Can we build a true human Avatar? More easily, I think, than meeting the challenge of shielding or adapting to the radiation. The braging rights might not be as great but the financial model might be more sustainable and expandable to flights beyond. Are we ready to invite a couple to forfit their DNA to science? We will probably get volunteers, but they should know the risks -- and the certain cost.

This is an aviation venture; that pioneering spirit is in our DNA, but before we get to hyper-drive and genetically modified humans, avatars might be a more efficient way to go.