The Cost of Childhood Obesity: Setting an Example for (Hope) & Change

Obesity and obesity related illness accounts for an enormous healthcare expenditure in the US today–approaching 150 billion dollars annually.  In an era of healthcare reform and cost containment, preventative medicine is essential to success.  Rather than rearranging networks, separating doctors from patients and limiting choice, our government may be more effective in reducing healthcare costs by focusing on slimming waistlines throughout the US.

According to a recent study in the Journal of the American Medical Association, nearly 30% of adults and 17% of children are classified as obese. According to the Centers for Disease Control, obesity in children has more than doubled in children and quadrupled in adolescents in the last 30 years.  Obesity rates in adults have remained constant–if not increased–over the study period.  In fact, in women over age 60, obesity rates have increased from 31 to 38%.   It is clear that obesity directly results in the development of diabetes, heart disease and other potentially debilitating chronic illnesses.

Data from previous studies clearly identifies habits developed in childhood as a primary determinant of obesity as an adult.  In fact, childhood obesity is almost always associated with obesity and health problems during adulthood.  This week, a study published in Pediatrics provided a specific cost analysis of childhood obesity and found that each obese child results in an individual $19,000 healthcare cost increase as compared to a child of normal weight.  Moreover, when the researchers multiplied the &19,000 figure by the number of 10 year olds who were estimated to be  obese in the US today, they calculated the total lifetime healthcare expenditure in this age group alone to be more than 14 billion dollars.

The adverse effects and negative impacts of obesity on our children stretch far beyond the staggering dollar figures that are illustrated in this most recent study.  Obese children are more likely to have risk factors for heart disease and are at increased risk for certain types of cancers.  Pre-diabetes is common in obese children and many develop Type 2 diabetes before adulthood.  Children with weight problems are more likely to suffer from depression and other mental health disorders including poor self esteem.  Development of such significant medical problems at an early age can prevent a child from truly enjoying the process of growing up and can limit choices and opportunities later in life.

Children of obese parents are far more likely to be obese themselves.  America is becoming a culture of sedentary adults (and now children)–increased calorie intake and diminished calorie output.  Our children model behaviors that they witness in adults and other mentors.  Modeling healthy habits such as regular physical activity and healthy eating can directly impact children and significantly reduce the chances of becoming obese.  Habits developed during childhood become part of our daily routine and are incorporated into our system of values and become second nature. If we, as adults, put a priority on diet and exercise early in life, we make it much easier for our children to develop and maintain a healthy lifestyle well into adulthood.

This most recent study should serve as a call to action–Americans are fat and are getting fatter.  The time to intervene is now.  We must set better examples for our children.  In a world full of fast food and calorie dense meal choices, we must do a better job demonstrating responsible lifestyle choices.  Fill the house with fruits and healthy snacks and avoid fast food meals whenever possible.  Help children learn to choose wisely.  Parents must encourage more outdoor activities, regular exercise and limit screen time.

As healthcare costs continue to rise,  we must focus on prevention.  Cardiovascular disease, diabetes, and high blood pressure are significant contributors to our overall healthcare costs and ALL of these diseases are more likely to occur in those who are obese.  As a nation, we must become more health conscious and make daily exercise and healthy eating part of our culture–only then will we be able to impact obesity and set an example for change.  Only then will we begin to reverse the obesity epidemic of the last 30 years and improve the lives of our children and the generations to come.

 

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Obamacare Delays and Rearranging Deck Chairs on the Titanic: Old People Can’t Surf

This week the White House announced yet another Obamacare delay–actually, to be precise, they termed it an “accommodation”.  The reason given for the delay was that there were concerns voiced by the Obama administration that the “rush” to sign up during the final days may cause delays and result in a website crash.  Therefore, it was proclaimed that those who were “trying to sign up” would be given an extension to mid April to complete the process.  Overall there have been more than 20 unilateral changes/delays/exceptions made by the President without Congressional approval or oversight.  Exceptions have been provided for businesses and those who serve and work in our Congress BUT the individual mandate remains in place.   In the meantime, many that have been counted as “signing up” have no insurance and a large number have not yet paid their premiums.  However, the biggest problem with the manipulation of the Affordable Care Act (ACA) may actually be the commentary of one of its greatest supporters–Senator Harry Reid.

With the 2014 Midterm elections looming, many of those in Congress who are facing reelection have commented on the latest delays in an effort to positively spin the news.  As you might expect, those in leadership roles such as Senator Harry Reid have tried to minimize the impact of repeated Obamacare failures and fixes on his part (a desperate attempt to cling to a majority). In an effort to explain the need for the latest delay Senator Reid has shown his complete lack of connection with the nation.  He publicly proclaimed and was quoted in the Washington Times as saying that “some [old people] may not be educated about [or understand] the internet”.  In reality, more seniors than ever before are utilizing the internet in order to maintain medical information.  Pew Research Center data indicates that as of 2013, nearly 60% of all Americans in the 50-65 year old age group are actively engaged in internet based social media.  Even more telling is the fact that 50% of those over the age of 65 are involved in AT LEAST one internet based social media outlet.  It is clear that the internet and medicine will be intimately connected in the future.  Twitter, a popular site for micro-blogging in 140 characters or less has seen a 79% increase in utilization by users in the 50-65 year old age group.  When you carefully examine the Senator’s comments he is clearly referring to those in the 50-65 year old range–those over 65 will be enrolled in Medicare and have no need to go to the exchanges.  The younger populations-such as the millennials–are assumed to be web savvy from birth.

The delivery of healthcare is already evolving digitally–particularly in the areas of the electronic patient and in mobile health applications.  For Senator Reid to make such a statement concerning the inability of older Americans to “understand” the internet not only is insulting but  shows a complete lack of connection to and respect for the very people he claims to want to protect.  Seniors are more web savvy now and are able to access the web in a variety of ways–there is data from non biased scientific surveys (such as those conducted last year by Pew) to substantiate my statement.  In reality, his comments are a sad attempt to explain the inexplicable–why do the Democrats in Congress continue to hang on to a system that is clearly failing?

The ACA continues to suffer setbacks–most of them at the hands of the President who has dedicated his legacy to its success.  The latest delay (or accommodation, as the Obama Administration prefers to call it) is more about the lack of enrollees and less about the ability of older Americans to successfully interact with the internet.  Many seniors are surfing on a daily basis.  The internet is not the problem with the ACA and healthcare reform–rather it is the legislation that is broken and badly in need of a fix.

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Demanding More Transparency in Big Pharma: The Battle to Force Disclosure of Data in Negative Trials

Research and development is critical to battling disease.  Now, more than ever, technology can rapidly impact a patient and their disease process in a very positive way.  The process of developing a new drug or device is expensive and can be very time consuming.  As government funding for projects continues to decline, more funding is coming from private sponsorship according to a recent New York Times piece.  Another critical source of research funding comes from the pharmaceutical and medical device industries. Partnerships with industry can provide additional opportunities for meaningful research.  When handled objectively and with clearly stated endpoints, these studies can produce impactful results.  However, as reported in both the New York Times and the Wall Street Journal (discussing two separate issues), these relationships can also begin to blur lines between academic endeavours, patient care and profit–often calling in to question the validity of the research.

In order to stay current and provide patients with the best available therapies, physicians dedicate many hours to reading new publications that evaluate novel treatments in peer reviewed journals or hearing about new therapies when data is presented at national academic meetings.  When data is compelling, most clinicians will change practice in order to incorporate what is perceived to be a superior treatment into our therapeutic regimen. Transparency of research–whether conducted through government sponsored grants or through industry funded projects–is critical to providing patients with the best available treatments.  The evaluation of the drug must be complete and we must be allowed to see all of the steps in the development process.  However, if there is more data “behind the curtain” we may not be getting an absolutely accurate picture of the safety and efficacy of the new therapy.  Lack of clarity in medicine when treating patients can result in unintended harm.

This week in the Wall Street Journal, author Hester Plumridge reports on groundbreaking European legislation concerning the regulation of pharmaceutical companies and their drug trials. The European Parliament is voting next month to consider requiring all data for all trials conducted in pharmaceutical research to be released for public consumption.   For years, pharmaceutical makers have been able to conduct clinical trials without reporting negative results if they choose not to do so. Most drug companies conduct numerous trials in an effort to develop new (and profitable) drugs to treat disease.  The process of drug development is tedious and can take many years to go from concept, to bench to clinical trials–and eventually to market in the US via FDA approval.  Now, for the first time, European legislators are working to approve a measure that would require all studies to be publicly reported within a year of completion–irrespective of the outcome.  Obviously, publicly held corporations are less than enthusiastic about publishing failures and disappointing stockholders.  However, there well documented reports of negative data that has been withheld from review and buried within emails and confidential paperwork within commercial organizations.  Many of these have led to litigation in the US and abroad.

Data from 2009 indicates that only around 50% of all trials conducted by pharmaceutical companies is actually published and released for review by the scientific community.  According to the Wall Street Journal, only 41% of over 600 studies sponsored by the National Institutes of Health (NIH) were published within 3 years of completion.  Many clinicians are concerned that the motivation for profit may ultimately do patients harm.  Withholding negative results related to a drug in development may result in incomplete data being presented to regulatory agencies such as the FDA–for example if a drug has one positive trial and two others that showed less benefit statistically, the drug could be approved without examining all of the evidence.  This approval may lead physicians to believe the drug is more effective than it actually is.  A well known example from the recent past involved pharmaceutical giant Merck and their drug Vioxx–in a well reported case, the drug maker was accused of failing to report cardiovascular related deaths, burying negative data and hiding risks to patients in order to gain approval and profit—ultimately they withdrew the drug in 2004 and have suffered significant legal consequences since then.

We must continue to innovate.  As the healthcare industry continues to scramble to control costs in the era of the Affordable Care Act (ACA) we must continue to put patients first.  Scientists and clinicians–whether in academia, private practice as well as in industry–must continue to work together and  disclose all data concerning the development of novel therapies.  It is essential to maintain absolute transparency when dealing with human lives.  Industry is a business and will always be driven by intense pressure to develop the next billion dollar revenue “blockbuster” drug–But we must be allowed access to the data surrounding the failures as well as the successes in order to protect the lives of the very patients we strive to heal.  Companies such as Johnson and Johnson as well as GlaxoSmithKline are beginning to lead the way in terms of openness and data publication.  Healthy partnerships between clinicians interested in performing rigorous research and industry leaders who are interested in innovation are key to success going forward.  It is my hope that the European legislation passes next month and that the United States will follow the lead of our European colleagues.

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Healthcare and the Ukraine: Politics, Suffering and Disease

 ****Written in response to the recent crisis  in Ukraine.

Certainly, the world’s eyes are focused on the political unrest in the Ukraine this week.  As a physician, I am concerned about the health and well being of the Ukrainian people. Healthcare in Ukraine is substandard at best.  Life expectancies in this region are well below standards that we see in the US and other developed nations.  For many throughout the world, the tensions and threat of military violence have created a great deal of anxiety.  After years of cooperation with Russia, it appears we may be on the brink of more Cold War type diplomacy.  Although the world is more interdependent and connected than ever, the international political events of the last week remind many of us of the events leading up to other world encompassing conflicts such as the second World War.  While the attention of the media and the world is focused on the military action and political rhetoric associated with the coup de etat in Ukraine and the Russian invasion of Crimea, the people of the region continue to suffer.  I wonder if the world’s leaders would feel the same way about the region if they had friends and family in Ukraine and knew first hand of the suffering and senseless deaths (due to the broken healthcare system).  It is easy to sit in power and remain out of touch with those that you claim to want to help.

Government Managed Healthcare in Ukraine

Healthcare in Ukraine is certainly far from what we in the US expect.  Overall, the healthcare system is neglected and there is an extreme shortage of adequate facilities, medicines and qualified physicians.  While some physicians are highly skilled and well trained, the majority of clinicians in practice never completed full courses of study but are thrust into service prematurely due to extreme need.  I am appalled by the lack of competency and training and I am concerned about the impact these practitioners may have.  Ultimately, I believe that the responsibility to provide adequate care in this particular system lies with the single payor–the government.  By law, all employed citizens contribute to the cost of the national helathcare system and all citizens have a legal right to healthcare access.  However, in reality, access to care is a significant issue.  The healthcare system is funded almost entirely by government revenues–citizens must play a fee for dependents and those who are self employed must also pay additional premiums.  For the most part, the government funds all healthcare fees.  However, physician wages are very low and many clinicians charge additional fees to patients, thus further limiting access to care for many citizens.  I believe that the lack of coordination of healthcare and the lack of reimbursement to providers significantly contributes to the poor state of care in the Ukraine.

Physicians and Facilities

Physicians in Ukraine are not well compensated.  General practitioners are the first point of contact for Ukranian citizens with the healthcare system.  According to the law, citizens may choose a physician they wish to see but must make sure that each provider is covered as part of the state controlled network.  Most doctors require additional fees for care that are collected from the patient at the time of surgery.   Waiting times are significant and urgent care may be difficult to obtain and may also require pre-payment.   I understand, given the poor wages, the need for physicians to collect fees up front.  However, it is difficult to imagine a system where compensation comes before care.  Hospitals throughout Ukraine are substandard facilities.  Even though there is a great need, there are few locations that have advanced equipment and supplies.  Hospitals are often very dirty and poorly staffed.  I believe this is another reason for the poor state of health in the Ukraine and the fact that the death rate continues to exceed the live birth rate–resulting in depopulation of the region over the last decade.

For those with means, there are private clinics that are funded either through cash payments or private insurance.  These clinics provide better access to care as well as better availability of specialists and specialized services or procedures.

Disease and Life Expectancy

Since achieving independence in 1991, Ukraine has seen one of the most significant demographic declines in the world–the population has been reduced by nearly 6 million.  The overall population has been reduced by nearly 12%–higher death rates are outpacing female fertility rates and depopulation has been the result over the last decade.  Men are dying prematurely and suffer very high disability rates due to chronic, non communicable disease.  Nearly one third of the population dies before age 65 and there are a disproportionate number of working age males with chronic, non communicable diseases.

Diseases such as HIV/AIDS and Tuberculosis are rampant and occur at much higher rates than anywhere else in Europe or Asia–these diagnoses account for nearly 90% of deaths from communicable disease   Due to government bias against homosexual behavior as well as high rates of prostitution, drug abuse and addiction, HIV rates in the Ukraine continue to rise.  There are virtually no programs in place for treatment or prevention of HIV related illness and many who are infected have little hope for treatment.  I believe that in order to succeed in reducing deaths and improving health status, the government of Ukraine must make treatments for HIV available and remove the negative legal and political stigma associated with the disease.

In addition, there is a very high rate of alcoholism (the highest in all of Europe in Asia) and many of the alcohol related premature deaths also occur in men.  I believe that much of this is due to the overall poverty in the nation and the associated depression of its citizens.  The average life expectancy of a male adult in the Ukraine is only 64 years old–72 for women.  Birth rates in the country continue to decline and live births are virtually outpaced by the premature deaths.

According to the WHO and World Bank, nearly 50% of all premature deaths in Ukraine could be prevented by regular and adequate preventative healthcare.  This is an astounding number and I see this as a real call to action for international healthcare agencies

What’s next?

Unfortunately, the political unrest and potential Russian occupation is going to do very little to improve care for the Ukrainian people.  Prior to the current uprising, the previous regime had a plan to revamp and reform the broken healthcare system beginning in 2014.  I worry that unless wholesale changes are made soon, Ukranian citizens will continue to suffer premature death and battle with chronic and preventable disease.  It is my hope that as the world focuses on the politics of the region that we also focus on the people and their plight.  Healthcare is just one issue that must be addressed but is essential to the recovery of the nation.

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Communication in Medicine: Lessons Learned By Wearing A Gown

Communication is critical to success in medicine.  Our patients depend on us to help them understand their disease and the risks that it may pose.  In previous blogs I have commented on how vital effective communication can be in determining outcome–much of my writing has focused on the success associated with outpatient doctor-patient relationships.  We now know that when doctors and patients engage, patients become invested in their own healthcare and are more likely to comply with lifestyle modifications and take medications as prescribed.  However, when a patient is ill and hospitalized, a entirely new level of complexity is added to the communication mix. The role of patient places one in a difficult position–you lose control, you lose your individuality and you may often become frightened due to the uncertainty of the clinical outcome.  The dynamic of communication in the acute hospital setting may be quite different in that the patient may be interacting with a new team of healthcare providers that they have no previous relationship with.  In addition, disease related factors such as pain, fever, and sedation may play a role in a patient’s ability to comprehend what is being said to them at any given moment in the hospital setting.  I can now speak to this from personal experience–this last week I became an unexpected patient.  I spent several days navigating illness and a complex yet compassionate hospital system.  My experience as a patient has inspired this particular blog–and has inspired me to become a more effective communicator in my practice.

This month in the New York Times, two articles were published that discussed different aspects of physician communication with patients.  Both pieces are important and should be read and carefully digested by both patients and physicians (as well as any other healthcare provider). In the first article, author Theresa Brown discusses the discussions that physicians and other healthcare providers commonly have with patients during a time of illness.  Particularly in the hospital, teams of providers at all levels enter a patient’s room and discuss all aspects of the case (Both with the patient and amongst one another).  It is interesting to realize just how much of what is said during these encounters is “lost in translation.”  During periods of illness, even the most educated and medically sophisticated patient can have difficulty comprehending exactly what the medical team is trying to convey.  Pain, worry, and emotional fatigue may all play a role in a patient’s inability to comprehend the clinical situation, the possible diagnoses, the testing required and the treatment plan.  In a separate article, authors Gilligan and Sekeres explore whether or not there are effective ways in which we may be able to teach better communication skills to physicians in training.  Several studies have demonstrated that no amount of training will convert an introvert to an extrovert communicator–however, communication training may open a healthcare provider’s eyes to the profound impact that their interaction with patients may have on outcome.  Once a provider is aware of the impact communication may have, they are more likely to be able to better engage patients and engage in a more effective way.

During my unexpected role as a patient this week, I often did not understand what to expect–even with my years of medical training and experience–I could only focus on my symptoms and my fear of the worst possible outcome scenarios.  During my patient experience, I interacted with many physicians, nurses and other team members–ER doctors, specialists, imaging technicians, transporters, etc.  My particular providers were very compassionate and spent a great deal of time attending to my needs and explaining their thought processes, differential diagnosis and treatment plans.  However, I was unable to process most of what was said.  I was often distracted by pain and my ability to assimilate and comprehend information was limited by the sedation I had been appropriately given.  Ultimately, emotion and fear would come to the forefront and dominate my thoughts, further limiting my ability to actively and effectively communicate with the medical team managing my hospital care.  My caregivers were dedicated and wanted only the best outcome for me and my family.  However, I was often confronted with large amounts of clinical information and I began to hear only pieces–I would latch on to particular words such as surgery and potential complications and would lose focus–no longer able to follow the conversation.  My ability to think rationally and effectively process clinical information (as I would as a physician)  was severely impaired.  I can only imagine what the experience would have been like for a non medically sophisticated person.

Fortunately, as the week progressed, my condition improved and I was ultimately discharged from the hospital.  My physicians and nurses spent time later in the week making sure that I understood what had happened to me and what the next steps would be.  My hospital stay and treatment provided me with new insights into the patient experience.   I now am able to envision ways in which I can improve my own interpersonal skills with my hospitalized patients–by actively taking time to make sure that each patient understands and truly hears what is being said to them.  From my experience, one of the keys to promoting  understanding is to provide time for questions–from both patient and family–during the inpatient hospital visit.  My caregivers did this often and it did provide comfort and some semblance of control.  (as much as one can have in an ill fitting hospital gown).  In addition, providing small, easily digestible bits of clinical information at several points throughout the day seemed to improve a patient’s ability to process and comprehend their condition, treatment and prognosis (at least it did in my case).  Although is is not practical for the physician to make multiple stops to the patient room throughout the day, phone calls for updates by the treating physician and visits by other providers such as nurses, PAs and NPs can make a difference in patient understanding and comprehension.  As Ms. Brown rightly states in her New York Times piece, hospitals and medical care are well focused machines–most providing efficient, quality life saving care.  We must remember, however, that we are treating patients–human beings with emotion and fear that can certainly impact a disease process.  We must take time to ensure that we not only provide the high quality efficient care but we also are able to care for the human being lying in the bed in the awkwardly draped hospital gown.

I am glad to be home from the hospital.  I am grateful for the wonderful care and compassion that me (and my family) received from many over the last week.  I am happy to be sitting outside in the sun writing this blog today.  I am excited about the opportunity my experience as a patient has afforded me.  I will take what I have learned and apply it to my practice–I hope to work every day to improve my communication with all of my ill and hospitalized patients.  Most of all, my experience has reminded me that although medicine is the application of science to the treatment of ailments suffered by human organisms, it is the human that really matters.  Our patients are people–they are often alone, frightened, emotionally exhausted and suffering.  We must all engage them in a way that best facilitates their understanding of their situation and focus equally on both treating a disease AND treating a frightened person lying in the bed before us.

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The Advantages to Team Approaches to Patient Care: Extending NOT Replacing Physician Care

Let me start by stating that I am a supporter of team approaches to medical care.  Data from numerous observational trials has shown that patient outcomes are improved when a diverse group of healthcare providers work together to coordinate overall patient care.  In my practice, we rely heavily on the excellent care provided by both Physician Assistants as well as Nurse Practitioners both in the hospital and in the clinics.  These physician extenders are essential to coordinating admissions, evaluations testing and treatments.

Last week in the Wall Street Journal, columnist Laura Landro discusses the new push for team based care in today’s healthcare market.  As Ms Landro states, there are numerous advantages to the team based approach.  Patients benefit from the more intensive one on one time that they are afforded with nutritionists, pharmacists, nurses and other advanced practitioners.  In previous decades, most of this work was solely the responsibility of the physician.  However, increasing demands for documentation and electronic paperwork have begun to consume physician time.  While the ACA promises to flood primary care offices with even more patients, physicians are scrambling to perform all of the duties that are currently required of them (with more government mandates on the horizon).   Most of my colleagues prefer to focus on patient care (rather than administrative paperwork and government mandates) but are often frustrated by how little time they have to interact with their patients.  Managing chronic disease is a process and requires numerous “touch points” with the patient in order to be successful.  In reality, as a cardiologist, I am able to see most of my stable patients only once a quarter–unless they have an acute event or decompensation.

It is clear that patients now are living with more complex diseases and that we have far more advanced therapies to treat them with.  Many of these therapies rely on strict patient compliance and on patients having a thorough understanding of their disease process and its management.  For instance, a patient with Congestive Heart Failure (CHF) may need to be able to interpret daily weights and adjust diuretic dosing accordingly in order to prevent hospitalization from a more serious CHF exacerbation.   Now, rather than see a physician for medication discussions every three months, a patient can make an appointment with a Pharmacist in our office and see them on a more frequent basis to discuss concerns over efficacy or side effects of their medical regimen.  In our experience, this has improved patient compliance and improved metrics such as blood pressure control and time spent in the therapeutic range for chronic anticoagulation patients.  Other primary care physicians report similar results when managing diabetes via frequent nurse educator or NP visits–patients seem to have more consistent control and better HbA1C results when they have more frequent touch points.

While a team approach is quite effective, each team must have a leader.  The team leader must be experienced and well trained.  While physician extenders do receive extensive training in a 2 to 4 year program, nothing replaces the years of experience that MDs obtain during residency.  In order to maintain a high standard of patient care, these teams must still be led by physicians.  With the cost cutting efforts and the changes that are occurring in healthcare due to the Affordable Healthcare Act, I am concerned that hospital administrators and government bureaucrats will ultimately attempt to replace physicians with other healthcare providers in the interest of curtailing costs.  Physicians are trained in real life patient care scenarios over a period of years–many residencies last from three to ten years depending on specialty.  The experiences of call nights and handling real time emergencies over a period of years (under the supervision of more experienced attending physicians) cannot be undervalued.  My experiences during my 7 years of post-graduate training at both the University of Virginia and Duke University Medical Center certainly shaped my clinical judgement and certainly sharpened my diagnostic abilities–I call on these experiences even today when faced with complex cases.  Efforts to replace physicians with other healthcare professionals with less intensive training may ultimately harm patient care.

Patient care comes first–I believe that a team based approach is essential to optimizing outcomes.  We must all work together–Nurses, NPs, PAs, Pharmacists, Nutritionists, and MDs–in order to provide the best possible patient centered care.  However, we must not attempt to replace physicians and the experience that they bring to the clinical arena in the interest of cost containment.  While balancing cost and optimal care is a slippery slope, we must always focus on the patient–nothing can or should replace the Doctor-Patient relationship–we must all work together to preserve the core principles of our noble profession and put our patients first.

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The Consequences of “Over-Testing”: Doc, Am I Glowing in the Dark?

In medicine today diagnostic testing and advanced imaging is readily available and widely utilized in most every clinical setting  Many physicians have given up the stethoscope and physical exam in favor of an echocardiogram and a CT scan.  Fear of “missing something” pervades every Emergency Department and has resulted in hundreds of thousands of unnecessary testing costing billions of dollars in healthcare expenditures.  Of course, the driving causes of increased testing and utilization of advanced imaging are numerous and complex.  Unfortunately, in my experience, the two most common reasons are fear of malpractice litigation and a desire for greater reimbursement.

How do we best determine when to test?

The most basic testing techniques rely on Bayesian statistics–the question to be answered must be well defined and then a clinician must determine a pre-test probability of the presence (or absence) of the disease in question.  The best utilization of a diagnostic test is when a clinician has an intermediate pre-test probability that a particular disease state is present.  If the pre-test probability is low, then there is no need to test.  If the pre-test probability is high, then the clinician should proceed with treatment rather than an additional testing step.  In the case of coronary artery disease, if you have a patient with multiple risk factors and symptoms that are a bit atypical, diagnostic testing with a stress test with imaging makes sense.  If you have a young person with no risk factors, and very atypical symptoms diagnostic testing does NOT.  In contrast, if you have a patient with classic angina, an abnormal EKG and multiple risk factors you may want to forgo diagnostic imaging and proceed directly to cardiac catheterization.

What are the risks associated with radiation?

In today’s New York Times, authors Redberg and Smith-Bindman argue that the over utilization of CT scans and other radiation based diagnostic testing results in a significant increased risk for certain types of cancers.  I tend to agree.  The radiation exposure associated with one CT scan is equivalent to more than 500 plain chest X-rays.  The FDA estimates that a patient’s lifetime risk of developing cancer from radiation exposure to a CT scan approaches 1 in 2000.  To place this all in perspective, the survivors of the atomic blasts in Japan were exposed to the equivalent radiation to two CT scans!  In addition to CT scans, nuclear medicine based stress testing in cardiology also exposes patients to large doses of radiation (even more than CT).  These tests are recommended at particular intervals by the American College of Cardiology in patients with known coronary artery disease (CAD) or in cases with suspected CAD with appropriate risk factors and baseline characteristics.  However, just as with CT scans, these imaging tests are often over-prescribed and overused.

What are the root causes for the over-use of diagnostic testing?

Much of the over testing seen in the US is due to fear of litigation.  Doctors, as a whole, want to do their very best for patients.  When the encounter a patient with a complaint that seems routine, many astute clinicians also think about more serious diagnoses when formulating a differential.  Anecdotes from colleagues where a particular serious diagnosis was “missed” can often lead to unnecessary testing.  Moreover, the trial lawyers and “ambulance chasers” are an ever present thought for many clinicians.  The fear of being sued for missing a lung tumor in an asymptomatic patient can also lead to more unnecessary and non indicated testing.  This phenomenon is yet another important reason that we must persue tort reform in the US today. Unfortunately, another reason for overuse of CT scanning and other types of imaging is profit.  Profit and finances have no place in the clinical evaluation of a patient–however, economic realities have blurred these lines considerably in the last decade.  There are some clinicians that put reimbursement ahead of patient welfare.  Abuses such as routine, non indicated imaging for cardiac patients has been declining.  New guidelines and more government and regulatory scrutiny into these types of exams seems to be having a positive effect on reducing unnecessary radiation exposures.

What can we do to advocate for ourselves and our patients?

As a patient, it is essential that you ask your clinician precisely why the test is being ordered and exactly what impact the result will have on your clinical management.  As physicians we must have very clear reasons (and well documented reasons) for ordering tests.  Tests should remain an adjunct to history and physical exam for the diagnosis of disease–not a replacement for clinical experience and expertise.

So, next time you order a test (or your doctor orders a test for you) make sure you take time to understand how the exam is going to impact your course of treatment–if you are at a fork in the road, the best test should determine whether you take the road to the right or the left…..If you and your doctor already know which way to go, the test may only be another chance to “glow in the dark…”

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