Monthly Archives: December 2012

Please Log On and Focus Your Webcam: The Doctor Will See You NOW!

It may seem like science fiction from an episode of the once popular futuristic cartoon series The Jetsons, but virtual doctor visits are now here.  As chronicled in a recent New York Times article, insurers are now rolling out services where patients can interact with physicians via webcams and receive treatment for minor illnesses.  Obviously, the insurance companies are motivated by lower costs–however, with a soon-to-be flooded healthcare system in the US today, virtual consults may also be able to ease the primary care shortage.  However, these novel doctor-patient relationships are not without controversy.  Many physicians warn of the incompleteness of the evaluation without a physical exam.  Government regulators worry over the lack of oversight–in fact, only 13 states actually recognize virtual visits as a true doctor patient interaction allowing the physician to prescribe drug therapy.  Many attorneys see this as an opportunity for even more lucrative (and frivolous, in my opinion) malpractice litigation.  But, ultimately, we must find new ways to simultaneously decrease healthcare costs, improve outcomes and reach the millions of Americans who desperately need  medical attention.

The idea of webcam medical visits is not a new one.  Many doctors in remote locations have used virtual consults to help make diagnoses.  In a recent bestselling book, Nantucket surgeon Dr Timothy Lepore writes about using electronic visits with specialists in Boston to help triage patients for medical evacuation to the mainland.  In this particular application of virtual medicine, a specialist or colleague is used to provide a second opinion;  the patient is still under the direct care of a physician who is present at the bedside.  However, the virtual consult proves critical in the decision of whether or not the patient should be flown to Boston for more advanced care (at significant expense).  I believe that webcam visits, when used in this context, can meet the goal of significantly decreasing unnecessary expense while at the same time improving care and impacting outcome.  Moreover, specialists are able to support general surgeons, family physicians and internists in underserved areas on a routine basis.  Rather than waiting for a cardiologist to show up to see patients in person once a month on the island, the cardiologist can see patients daily via virtual visits.  Care becomes more efficient and remains centralized through the primary care provider.

In contrast there are other things about remote physician visits that are less than ideal.  In my previous blogs, I have written about the critical nature of the doctor-patient relationship.  It has been shown in many different studies that engagement of patients in their own healthcare clearly impacts outcomes.  I worry that in routine visits with a virtual doctor that no real engagement can occur.  Regardless of all the fancy bells and whistles now available to physicians, the practice of medicine remains a very personal and human relationship.  Eye contact, gentle touch, non verbal cues and body language–all important in a human relationship–do not translate well to a virtual visit.  Much of the art of medicine is found in the relationship between doctor and patient.   In all fairness, there are ways that relationships can be built via virtual visits–regular webcam “appointments” with the same provider will go a long way to making the best of the lack of physical presence.  Just as in a regular doctor visit, follow up is critical to success.  From a diagnostic side, much information can be gleaned from the physical exam.  In a virtual visit, observation is still possible but there is no way to place a stethoscope on the chest or to palpate the abdomen.  Many of my mentors in medical school stated many times over my years of training that “80% of diagnosis in medicine is the history and physical exam”.  This lack of a physical exam cannot be bridged or replaced without a physician at the bedside.

As in most areas of medicine, government regulation will be looking to play a major role in virtual medicine.  Currently only 13 states recognize webcam visits as an actual physician encounter.  In order for for a physician to legally prescribe a medicine, a well documented visit must occur.  For virtual doctor visits to be a viable option, legislation must address these types of visits.  In addition, medicare and other third party payors must be given guidelines and codes (yes, more codes) in order for billing and reimbursement to occur.  For physicians, particularly in this time of declining reimbursements, adequate compensation for time spent in virtual office visits and consultations must be quantified, defined and approved by both insurance companies and government agencies alike.

Lastly, we must deal proactively with the inevitable litigation that will come with webcam or virtual physician encounters.  I am certain that the trial lawyers out there are already looking into ways in which virtual physicians can be sued.  In order to have any opportunity to curtail healthcare costs and implement remote medicine, we must continue to push for tort reform and limit the activities of litigation-happy attorneys.  That topic, however, is much too big to address here–it will require its own blog entry altogether.

Ultimately, I believe that virtual medicine and webcam consultations will be an important part of medicine in the future.  However, there are many challenges that must be faced as we implement these new technologies.  Most importantly, we must preserve the art of medicine and continue to provide excellent patient care.  Physicians, insurance companies, government agencies (and even trial lawyers) must work together to make these new innovations both possible and cost effective.

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Primary Care Shortage? It’s Time to Examine Medical Education in the US

When I was in medical school in the 1990s, students were given a bleak picture of the life of a subspecialist. We were told that there would be few job opportunities and that the only way to ensure a job was to pursue a career in primary care. Many of my classmates did go into primary care but the majority of us accepted residency positions in surgery, neurosurgery and other medical subspecialties. As we completed our training, we found that there were actually plenty of job opportunities for subspecialists. In fact, other than in underserved areas, shortly after my graduation from medical school primary care doctors were abundant. However, times are now much different. As discussed in the New York Times this week, it is becoming more and more difficult for patients to find primary care doctors. In a very short time, there will be more than 40 million newly insured patients that flood the system. All of these patients will need primary care providers.

Today’s medical students are saddled with enormous debt. The average cost for a medical education at a public university is $29K per year for four years; the median cost at a private school is nearly $50K per year for four years. Many students leave medical school and enter residency training programs with between $200 to $300K in debt. The cost of a medical education has risen almost 300% over the last 20 years. Now, particularly in primary care, salaries and reimbursements are significantly lower than in previous decades. Add to that the ever-increasing burden of paperwork and administrative duties that are required of primary care physicians and it becomes obvious why there is a shortage of newly trained primary care practitioners. Many students pursue a medical education to make a difference and to help people–many enter school wanting to be primary care providers and work in underserved areas. However, the financial realities of debt often force students to change their minds and seek residencies in subspecialties that hold the promise of better financial return.

Healthcare reform is important. We must focus on providing quality care to patients who need it in the US today. However, we must also reform the medical education system. No longer can we continue to allow the costs of tuition to rise to astronomical levels and at the same time lower the potential earnings for medical school graduates. If we continue on the current path, we will make a medical education an “upside down” investment. Moreover, allowing the tuition of medical schools to soar will make it more difficult for bright students with limited financial means to attend. We will, in fact, self-select medical school classes of the financially privileged and prevent other very talented less affluent students from attending. Although I was fortunate enough to receive an academic scholarship to medical school, I often ate macaroni and cheese and ramen noodles for weeks at a time in order to make ends meet. I had a job moonlighting as an MCAT preparatory course instructor. But, I did have access to an excellent medical education. In addition to containing the cost of a medical education, we must also address the issue of the investment of time–is it really necessary for physicians to attend four years of undergraduate work and then four years of medical school? In many countries in Europe, a combined track of 6 years produces well trained physicians that do very well in US residency training programs. Many students do not begin their careers until their early 30s due to the combination of undergraduate and graduate degrees coupled with prolonged fellowship training programs.

The US offers some of the very best training for physicians in the world. We are fortunate to have some of the finest institutions with cutting edge technology. Our students are able to be trained in the most sophisticated medical procedures and are able to participate in research that makes a difference in the lives of many patients. However, the medical education system in the US is currently broken and something must be done to fix it quickly if we are going to keep up with demand. No longer can we squeeze the young physician at both ends–astronomical educational costs, prolonged times to acquire both undergraduate and graduate degrees must be addressed as salaries and earning potentials continue to be regulated, lowered and limited. Primary care doctors are essential. They are the entry point for patients and the stewards of our healthcare. Yes, there is a shortage of primary care physicians today and even greater shortages loom ahead. In order to fix this problem, we must closely examine the system and make changes that allow for access for all qualified students with a more reasonable time investment. In the end, our goal should be to produce the best physicians in the world, who are motivated to care for the patients who desperately need them today and in the future.

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Honoring The Newtown Victims: Making Sense out of the Senseless

The events of the past week in Connecticut hopefully have given us all pause to appreciate the fragileness and uncertainty of life.  We have all cried with heartache for the parents who have lost children.  We have honored the adults that gave their lives to protect the students in their charge.  We have all stood with outrage at the senselessness and brutality of this crime.  As time passes, the families of Newtown will begin to heal–but they, like all of us, will never forget.  The brutal massacre in Newtown has brought many issues to light.  In the days to come there will be the obvious political discussions concerning gun control–however, politicizing this tragedy  is not my purpose in this blog.  Beyond dealing with my own anger and feelings of sorrow, one of the most difficult things that I have had to do is to figure out how to talk with my daughter about the Newtown school shootings.  Children of all ages throughout our country have been or will be affected by this terrible occurrence.  In order to process the tragedy, we must learn how to discuss the events with each other and with our children.

As described in the New York Times today, finding the right words for victims and their families is often difficult.  Even clergy, who are regularly faced with providing consolation to those who suffer have struggled with the Newtown tragedy.  There is much debate by parents and psychologists as to how best deal with the news.  Some, like author KJ Dell ‘Antonia in  her New York TImes blog, suggest that we many not need to talk to younger children about the tragedy at all.  Rather, she advocates the practice of finding out just “how much” they actually know about the news and reacting to that.  For children who do know something about the events, Ms Dell ‘Antonia suggests the concept of pairing a “brave thought with a worried thought”.  That way when the worried thoughts enter a child’s consciousness, the brave thought will follow close behind.  Often, we subconsciously want to talk to our children about tragedy, more for ourselves than for them.  As parents, we have a need to protect and to nurture.  Talking about the events helps us process and helps us feel that in some way, we have made our children safer.
The American Academy of Pediatrics recommends that parents use available resources to talk to their children about the Newtown shootings.  However, limiting media exposure and adult conversations is also highly recommended.  Gauging the child’s level of interest and anxiety concerning the tragedy is the key to determining how much to share.  Most experts suggest that the best way to discuss a traumatic event is to listen first.  Reassure your children that even though bad things can happen, their world is still a relatively safe place.  Provide love and support.  Acknowledge their fears and help them know how much they are loved and cared for by family, friends, and teachers.  The AAP does warn against changing routines–children are creatures of habit and when the normal daily processes are disrupted, anxiety can be created. For older children who struggle to cope, psychologists suggest that engaging in projects such as fundraising for relief funds, writing letter to affected communities or expressing their feelings through art or writing can often help children process sadness and grief.  Experts warn however, that if a parent is stressed and upset about the event, the time for discussion with the child should be delayed.

The tragedy of Newtown, CT will not pass quickly.  We can honor the victims of the massacre by engaging in conversation–with each other, and with our kids.  Listen to your children, help them cope.  Bond tighter as families.  Take advantage of every moment together.  As we enter this time of holiday celebrations, feasting and family togetherness, focus on the joy of the human experience, not the hassle of the lines at the mall or the annoying family visitors who never know when to leave.  Treasure the preciousness of time–that is the best way we can honor the victims, their families and the citizens of Newtown, CT.

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Singing the Blues: Stress, Depression and Risk for Stroke

Depression is common in US adults over the age of 65.  As we age, we are faced with our own mortality and often lose family and friends to disease.   According to the CDC, over 80% of elderly adults have at least one chronic medical condition and nearly 50% have more than two.  Dealing with multiple prescription medicines, multiple doctor visits and treatments add stress to life.  Many seniors live on fixed incomes and financial pressures are often quite significant.  To make matters worse, seniors are often misdiagnosed and many medical professionals do not recognize depression in this age group.  Many physicians believe that feelings of sadness experienced by the elderly is just part of the natural aging process.  Older patients themselves do not even recognize that they are depressed and believe that their feelings are part of the natural aging process–they never seek help.

Just a few days ago, the AHA Journal Stroke published a study linking increased risk of fatal stroke in older Americans.  In the study, over 4000 adults in the Chicago area were followed and their level of psychological distress was measured using standardized, reliable assessments.  The results of the investigation demonstrated a statistically significant increase in both fatal and nonfatal stroke in patients who were depressed and had increased levels of psychosocial distress.  Clearly, there is an association between mental health and cardiovascular disease.  Prior studies in patients with congestive heart failure have also demonstrated negative outcomes in patients with untreated or concomitant depression.  In fact, in this newly published stroke study, a clear dose response relationship was seen between the level of psychological distress and stroke;  those with higher levels had a 2 fold incidence in fatal stroke and a 30% increase in incident stroke rate.As scientists, we are driven to demonstrate a cause-effect relationship when approach disease.   In order to treat a disease, we must target specific biologic connections.  However, the biology of the association between stroke and emotional distress is difficult to definitively determine and has yet to be proven.  Several biologically plausible hypotheses have been offered:

1.  Emotional distress and depression may create higher levels of stress hormones and inflammation that contribute to events.

2. Patient who are emotionally distressed and depressed may be more likely to be non compliant and unengaged in their own healthcare.  They may be more likely to live unhealthy lifestyles.

3. Emotional distress and depression may produce a hypercoagulable state where a patient is more likely to form a thrombus and experience a thrombotic event (embolic stroke).

The emotional well being of a patient can clearly have an impact on cardiovascular health.  As healthcare providers, we must diagnose and treat depression, anxiety and other mood disorders as part of routine care.  As cardiovascular healthcare professionals, we must develop relationships with mental health providers, counselors and psychiatrists so that we are able to refer our patients for specialized care when appropriate.  The link between emotional health and physical illness is real.  The heart-brain connection has been reported in the past and studies such as this one in the journal Stroke continue to emphasize the complexity of this association.  Elderly patients are at particularly high risk for the detrimental effects of psychological distress simply due to its high prevalence in this population.

As we enjoy the holiday season and move to the New Year, let’s all commit to providing comprehensive care for our patients.  Let us all strive to recognize signs of psychological distress and help our patients deal with their feelings in a productive, positive way.  Help our patients by recognizing financial strain and prescribing generic medications.  Make it clear to your older patients that depression and sadness is NOT a part of the aging process.  Help integrate care by communicating with primary care providers and other specialists in order better coordinate care for our patients.  Regardless of the specific biology of the association between emotional distress and cardiovascular disease and stroke, we can reduce risk by helping our patients to improve their own psychological health.

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Healthcare Reform and The Cost of Prescription Drugs: Price Gouging or Providing Hope?

There are many factors that have contributed to the massive healthcare expenditures in the US today.  Costs of technology, costs of hospitalizations and hospital based services, physician fees, drug costs and costs of litigation (see tort reform and how Senator John Edwards made his fortunes) are all major factors that drive the cost of care higher.  To be effective, healthcare reform must address ALL of these aspects equally–regulation and cost containment must be applied to each of these entities in order to successfully lower cost while maintaining quality care.  One area that does not receive enough attention in healthcare reform discussions is that of drug costs.  In 2010, Americans spent nearly 262 billion dollars on prescription drugs.  Since the beginning of the new affordable care act (ACA) Americans have only saved a modest 3.7 billion in prescription drug costs.  I argue that this is not nearly enough.  Many new biologics and so called designer drug therapies are being produced at enormous expense.  Many of these therapies have not been shown to significantly impact disease survival.  However, they do often provide hope for patients left with few options.

Yesterday in the New York Times,  I read another wonderful article by cancer patient Dr Susan Gubar.  Once again, Dr Gubar inspires with her words.  In her blog, Dr Gubar discusses the expense and frustration associated with drug therapy.  Often  availability and production become an issue for desperate patients.  Costs prohibit access to new therapies for many.  As Dr Gubar points out, it is often the most vulnerable that are harmed by drug shortages and outrageous costs–kids with leukemia, and the elderly.  Our system of drug development and marketing has been entrusted to businessmen and women who are held more accountable by Wall Street investors than by the patients they serve.  This is not to say that pharmaceutical executives do not care about the patients that their drugs impact–however, they do care a great deal about PROFIT.  A good example of this was revealed in a pre reform New York TImes article from 2009.  In this article author Duff Wilson reports on the pharmaceutical industry’s practice of raising drug prices in advance of healthcare reform legislation.  The drug makers raised prices over 9% in a move to limit their profit reduction when potential federal mandates arrive that force them to lower prices.  In effect, the industry has attempted to  set up a higher price base prior to the inevitable reductions that will come with reform.  In essence they are hoping for a net zero change–certainly these types of strategies will limit any reform’s ability to contain costs.  This is just plain wrong and is reminiscent of the price gouging that is seen after natural disasters such as Hurricane Katrina.

Healthcare reform is here.  How it is implemented remains up for some debate.  To be successful we must address all factors that are driving up the cost of care.  Drug makers must be held accountable to the Americans who depend on their therapies.  Pharmaceutical cost  must be regulated and the cost of new biologics must be weighed against their effectiveness.  There is no debate that outcomes data has to be a part of this type of decision making process.  Patients depend on a constant and reliable supply of certain drugs.  We must hold drug makers accountable for shortages–we must shift the pharmaceutical executives focus from making expensive, new designer drugs to providing quality service and a reliable supply at a fair cost.  Do I have an answer for this?  Most assuredly I do not.  However, we must all come together–physicians, politicians, pharmaceutical and other industry executives as well as patients to find some common ground.  It is only thru cooperation and compromise that the real healthcare reform in the US will come to fruition.

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Eat, Drink and Be Merry (But Choose Wisely): Taking Individual Responsibility to Reduce Healthcare Costs

Cardiovascular disease is the number one killer of both men and women in the US today.  Medicine has many advanced therapies to treat heart attacks and strokes.  However, one of the most powerful tools in the battle against sudden cardiac death is prevention.  Certainly, modification of risk factors and heart healthy lifestyles are a big part of successful prevention.  This past week in the Wall Street Journal, I came across an article reporting the effects of diet on lowering the risk of heart attacks.  In the report, investigators looked at the impact of diet in addition to medicines in patients who already have cardiovascular disease.  As I read the article, I began to reflect on how important it is for patients to take responsibility for their own health.  In the US today, diets are often high in calorie dense foods with disproportionate amounts of fat. Economic pressures have people working harder with longer hours and fast food intake is commonplace–all resulting in poor nutrition.  Many studies have been conducted over the years that have demonstrated the relationship between diet and type 2 diabetes, high cholesterol as well as other potentially devastating diseases.  With healthcare costs rising and reform on the horizon, prevention and patient engagement is critical to disease management.  Many expensive diseases and medical interventions can be avoided through prevention–the first step in reform must be to create a healthier population.  Ensuring that all citizens have access to healthcare is only half of the equation–with healthcare coverage comes individual responsibility.  Each American must make changes to diminish their risk for disease.  Diet is an important part of lifestyle modification.

The basis for the Wall Street Journal piece is a recent study published last week in the journal Circulation.  In the study, over 30,000 men with known cardiovascular disease in two separate databases were evaluated using two reliable dietary indexes.  The study found that in men older than 55 years old, that those with a healthy diet reduced their risk of sudden death by 35%, recurrent heart attacks by 14% and stroke by 19%.  In medicine, we are often excited by interventions that lower mortality by a few percentage points; There are very few interventions in medicine that reduce mortality and outcome by nearly a third.  If we put these findings in context with other medical interventions that reduce mortality we find that this is an incredibly significant finding.  Only colon cancer screening and breast cancer screening have shown similar reductions in mortality.  Moreover, prevention through dietary changes is a relatively cheap intervention when compared to other advanced therapies for patients with known cardiovascular disease.  For example, with expensive interventions such as the implantation of Implantable Cardioverter Defibrillators (ICDs) we can reduce sudden death by an average of 30% in appropriately selected patients.  ICDs cost the healthcare system upwards of 20K dollars each (not including hospital and physician charges).  Lifestyle modification and diet are relatively inexpensive.  In fact, cooking healthy meals at home is likely to be less expensive than a trip to the local McDonalds restaurant.

What are some healthy choices?  In the Circulation study, the healthy choices that were shown to have an impact on the reduction in death from cardiovascular disease were as follows:

1. Limit the intake of sugary beverages and sodium

2. Eat at least four cups of fruits and vegetables daily

3. Four servings of nuts or seeds a week

4. At least two servings of fish per week.

This list is not comprehensive.  It is just an excerpt of a set of guidelines developed by the American Heart Association.  In addition to what you should eat, we must remember what to avoid–calorie dense, high fat, nutrient poor foods.  Unfortunately, these poor choices are abundantly available and often easy to access quickly.

 

During the holidays, we are busier than ever.  We must make time to improve the health of ourselves as well as our families.  Certainly, the holiday season is a time to celebrate and indulgences are commonplace.  Take time to make healthier choices.  Give the gift of a well balanced, well thought out meal to your family.  Instead of fast food, grill fish or make a seafood salad.  The costs are the same (or less) and there are recipies available that are simple and quick.  Involve the children in food preparation and make cooking a family activity.  Begin a culture of better healthy in your home.  Healthcare reform is underway.  It is going to be expensive–as individuals we must play an active role in our own health if reform is to be successful.  All the coverage in the world is not going to be effective at reducing disease and death in the US unless we all focus on prevention and improved lifestyle choices.  So,  As we near the stroke of midnight on December 31st, let’s all commit to healthier eating in 2013.  Eat, Drink, and Be Merry (But Pledge to Be Healthier) as we ring in the new year.77262-400x265-Healthy_Eating_Plans   happy-new-year-300x290

The Ultimate Battle for Supremacy: Doctor versus Machine

For many years, authors and movie studios have imagined a world where humans are replaced by mechanized overlords–think Terminator and  Matrix.  In medicine, as technology continues to evolve, computers and other diagnostic aids are readily available.  Many offices and hospitals utilize tablet computers, iPads and other fancy tools when managing patients.  Although he practice of medicine is closely coupled to complex technology and computers, it is at its roots a very personal and intimate interaction between two or more human beings.  However, computers such as IBM’s Watson are now able to solve complex problems and synthesize data to provide medical diagnoses from inputted data.  It is only natural that some scientists (and businessmen) want to replace doctors with machines.

This week in the New York Times, author Kate Hafner explores this very issue.  As a medical student at Wake Forest University, a resident at the University of Virginia and then as a Fellow at Duke University, I can remember going to case conferences and marvelling at the diagnostic skills of senior faculty.  Often, an unknown case would be presented to the institution’s best medical diagnostician by the Chief Residents.  These medical “superstars” would have absolutely no preparation and would have only the hour of the conference to come up with a diagnosis.  History, physical exam and routine laboratory data would be provided in a case presentation.  The “superstar” would then be allowed to ask questions and order tests. If the test result was actually performed on the case the result would be provided.   At the end of the hour, the diagnostic superstar would mesmerize the crowd with a summary of the findings, describe his thought process and provide his top three diagnoses.  Without fail, he would then provide the correct diagnosis AND his reason for his decision.  A hush would fall over the auditorium and the Chief Resident would announce that once again, Dr Superstar had made the right diagnosis.  As physicians in training, we would leave INSPIRED to become better doctors.

Computers are able to process incredible amounts of information quite quickly.  In the New York Times article, the author explores the value of intuition and gut instinct–certainly computers are able to process vast amounts of information very quickly and come up with viable diagnostic options.  Humans are quite adept at recognizing patterns.  Pattern recognition is essential to making accurate diagnoses.  As Ms Hafner mentions in her article, the “superstar” diagnosticians must combine a good fund of knowledge with logic, pattern recognition and intuition.  No computer is able to combine all of these factors.  However, when a physician does this type of diagnostic work, it is done at human speed.  Computers can quickly crunch numbers and work through pre- defined algorithms and provide a list of diagnostic possibilities in an instant.  Computers require programmers.  Doctors require medical school, residency, fellowship and most importantly EXPERIENCE.

Physicians are essential to the practice of medicine.  Computers and computer algorithms can help to manage and catalogue vast amounts of medical information.  Neither a physician nor a computer can practice medicine alone in a vacuum today.  As medical science continues to rapidly develop computers are very useful resources.  Creating algorithms for problems solving and diagnosis is important–not as a Dr Superstar replacement BUT as an adjunct to diagnosis.  By its very nature, medicine is all about human contact and human interaction.  There are many subtleties to complex diagnosis that can only be picked up on by TALKING to and EXAMINING the patient.  As we move forward with healthcare reform and begin to make tough decisions about cost effectiveness and efficiency of care, we must keep in mind the importance of clinical diagnosis by a PHYSICIAN.  The practice of medicine is certainly a science but it also remains an ART.  Just ask Dr Superstar, in an hour, he will amaze you with the right answer…every single time.

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