Monthly Archives: January 2013

Tracking Health Indicators: The Role of mHealth Technologies in Improving Outcomes

Smartphones, tablets such as the iPad and other mobile technologies are becoming commonplace in the US today.  These devices are nimble, efficient and able to process large amounts of data while conveniently sized.  In a recent survey in 2012, it was found that nearly 95% of all Americans have mobile phones and 60% have smartphone devices.  The numbers are a bit higher in the younger age groups but the devices are prevalent even in the over 65 set.  Tablet computer sales are expected to overtake laptops in 2013–one estimate predicts that 240 million tablets and 204 million laptops will be purchased this year.  With technology at everyone’s fingertips, it is not surprising that more and more patients are using technology to track their medical conditions.

The New York Times recently reported on a survey published by the Pew Research Center on American’s health tracking behaviors.  Fortunately, as a society, it appears that we are becoming much more health conscious.  In the survey, Pew researchers found that 70% of all adults track some health indicator for themselves or a loved one.  However, much of the tracking is classified as informal and 49% say that they track “in [their] head”.  Of those who track health indicators, 35% use a paper journal and now 21% use technology such as a smartphone or tablet application.  As mentioned in the Pew report, this is the first survey conducted to examine health tracking behaviors in the US–Importantly, the survey found that 46% of those with tracking behaviors changed their approach to healthcare and have become much more engaged.  Specifically, the engagement prompted them to ask more questions of their physician and to often seek more that one opinion.

Mobile technology is a powerful tool.  Last year alone over 500 companies made healthcare related applications and there are now almost 15,000 applications for health indicator tracking on the market.  By tracking health indicators such as blood pressure, heart rate, daily weights and blood sugars (among others) patients can see the impact of interventions such as diet, exercise and drug therapy.  Seeing results in real time can be very motivating.  The ill effects of chronic diseases such as hypertension and obesity are not always readily apparent to patients until end organ damage occurs.  With tracking applications, the patient is able to see the day to day variation and is engaged in the control of his or her health indicators.  As I have mentioned in a previous blog, I believe that the time is near when physicians will begin prescribing mobile health tracking applications for their patients during routine office visits.  Healthcare in the US has to change in order to be successful.  No longer can patients passively sit back and accept the fact that physicians will be able to take care of all of their healthcare needs.  Now, more than ever, patient engagement and participation is key to success.  Under the new healthcare system, physicians will face increased pressure to see more patients in less time.  Documentation challenges with electronic medical records (EMR) and other paperwork will further diminish the time spent with patients.  Patient participation in health maintenance through health indicator tracking via mobile applications will prove to be a critically important part of our healthcare system.  I foresee a doctor’s visit where a patient can download their smartphone data directly into their EMR file in their physicians office.  This ability to sync data will not only save time but will improve accuracy of the record.  Ultimately, I expect that mobile applications will be able to transmit data messages to physician offices when certain health indicators have risen to dangerous levels.

Technology to improve the health of Americans is here.  How and when we incorporate these technologies into the healthcare system is still developing.  As with most things in medicine in the US, the FDA will most likely begin to play a larger role in the evaluation of health tracking applications.  Ultimately, I expect the same level of regulation that we see with new prescription drugs or medical devices.  (However, that could be  subject of a blog all its own).  For now, I encourage patients and physicians to consider using medical applications in their practices.   Certainly, tracking indicators can benefit patient outcomes–patient access to data increases awareness, increases engagement and will ultimately save healthcare dollars.


The Cost of Diagnosis: The Sometimes Fatal “Incidentaloma”

I can remember making rounds with a seasoned surgical attending in medical school.  In typical fashion, surgical rounds were a lot like the military.  The “General” (attending physician) at the front, always commanding respect (and often fear) followed by the chief resident, junior residents, interns and finally medical students.  Cases were presented, statuses were updated and plans were formulated.  Then came the barrage of medical fact questions–mostly directed at the interns and medical students.  These questions were akin to an oral exam conducted in front of the entire school. When discussing one particular case where a lung mass was discovered on a routine yearly chest x-ray, we were asked for a single diagnosis–I knew that all the biopsies were negative and that the patient did not have cancer.  The entire work up had been negative.  Most answers revolved around the tissue diagnosis of “fibrotic changes likely related to prior fungal infection”.  This was not the answer our fearless leader was looking for–like most questions during rounds with the “General”, there was always a twist that would lead to an important teaching point.

Here is a little background on the case…The chest x-ray had been ordered during a yearly physical exam in the patient’s internist’s office in addition to yearly blood work such as thyroid panel, chemistries and cholesterol.  There had been no suspicion of lung disease and no specific symptoms that would prompt this examination.  The patient was quite healthy, exercised daily and was in great shape overall.  But, once a mass was discovered, the finding had to be worked up.  CT scans revealed a suspicious looking abnormality.  Review of old chest x-rays did not show the mass in the past.  Tissue diagnosis was then the next step.  We had to make sure the patient did not have cancer and utilize every possible test in the medical arsenal to rule out the “bad”.

The patient subsequently underwent an invasive procedure in the pursuit of a definitive diagnosis.  Along the diagnostic journey a few complications occurred including a pneumothorax (collapsed lung).  The complication resulted in yet another procedure to re-inflate the lung (insertion of a chest tube) and subsequently more X-rays and scans were required.  The preoperative testing, the biopsy itself, the hospital stay following the complication and follow up imaging resulted in both emotional and physical pain and anguish for the patient.  The patient worried over a possible deadly diagnosis and then suffered through the pain associated with the insertion of a chest tube.  Moreover, significant costs were generated and borne by both patient, hospital and insurer.   Imagine the cost to the healthcare system if this had been an uninsured patient.

During the course of questioning by the attending, answers were put forward from every student and intern and he was dissatisfied with all of them.  The answer he was looking for:  “Incidentaloma”.  He defined an incidentaloma as a medical finding that occurs by chance and that often leads to further testing and procedures–often putting patients at risk for complications.  The “General’s” point was that we must order tests responsibly and we must be prepared for the results–either positive or negative.  A test should serve as a map that directs us to the left or the right when we come to a fork in the road.  Simple Bayesian statistics, right?  Always begin a test with a hunch, a “pre-test probability”.  A test works best when the pre-test probability is in the intermediate range.  If the pre test probability is very low, you don’t really need to perform the test.  If the pre test probability is high, then you need to begin therapy rather than conduct another diagnostic test.  Well, as we all know, medicine is NEVER just that simple…

Last week in the New York Times, an article was published by Dr Danielle Ofri discussing the “fallout” of chance medical findings such as the case I have described.  In similar fashion, her case demonstrated the costs and frustrations that can be associated with an “incidentaloma”.  Certainly, neither my well respected, learned surgical attending nor I would ever suggest that we do not look into abnormal findings.  I am also not suggesting that we do not perform routine screening tests.  What I am suggesting is that we order tests thoughtfully and with purpose.  We must do our very best to use the best data we have to evaluate the value of available screening tests.  We all know that early detection of breast cancer, colon cancer and other potentially life threatening diseases can certainly impact outcome.  There will always be controversy when it comes to using diagnostic tests for routine screening of asymptomatic patients.  Even today, there is much debate over screening for prostate cancer and when to begin routine mammography scans.  Ultimately, we must continue to take a reasonable and academic approach to testing.  We are still going to discover the “incidentaloma”.  Our challenge is to carefully handle these occurrences–we must balance them in a way that protects our patients from undiagnosed occult disease while at the same time, protects them from the dangers of the “10 million dollar” workup of the chance medical finding.


Practicing Medicine Like An Elite Athlete: Competing Against Disease At The Highest Level

Athletes inspire us. Often under challenging circumstances, these gifted human beings rise to meet and beat what appear to be insurmountable odds. Long distance runners, Ironmen (and women), professional football players and countless others–are able to fight through pain, and adversity and ultimately excel at the highest levels. We can learn a great deal from these extraordinary people. As physicians, we are involved in a high stakes “competition” against disease every single day. So, how do we raise our game to the elite level? How do these amazing athletes do what they do?

A recent article in the New York Times explored the training habits and philosophies of elite athletes. Much of what the successful athlete does to prepare for competition can readily be applied to our daily lives and careers.

1. Focus: Successful athletes identify goals early in their careers. They set these goals apart and develop a plan to achieve them. To achieve these goals, repetition and practice is required. In medicine, a lot of what is done during a day may seem routine–making rounds, follow up office visits, and paperwork. During the performance of mundane tasks, often our minds wander and we daydream. Many elite athletes note that when they focus on each activity–no matter how routine, their performance improves. As physicians, our ability to provide excellent care may very well be enhanced by employing a similar tactic. Remaining focused–even when performing tasks that we have performed millions of times before, makes us better. We may pick up on a subtle physical exam finding, or discover an important historical fact during an offhanded comment made by a patient during an office encounter. Focus makes us better. Focus allows us to go beyond the ordinary and excell. Most importantly, focus allows us to give our best to our patients.

2. Managing Your “Energy Pie” : Sports psychologist Dr David Martin speaks of “energy pie” as all of the things in life that take up time and effort. In his opinion, the key to an athlete’s success is closely tied to managing this energy pie well. Limiting distractions and avoiding the pitfalls of spreading oneself too thin are critical. In medicine, we must set priorities. We must put our patients needs first. We must also balance family life. Avoiding unnecessary conflict and expending effort (and thus a piece of the precious pie) only limits our success. We must carefully choose where and when to expend effort.

3. Structure Your “Training”: Elite athletes have remarked that one of the keys to success is to partner with a coach that helps to provide meaning and purpose to training. Each workout has an objective and all effort is with intention. In medicine, when our activities are streamlined and structured, we become more efficient and more successful. Ensure that everything you do during the day has a purpose and at the same time allow for “recovery” activities. Just as elite athletes may have a day for recovery where they may focus on stretching, yoga or other less strenuous activity, we must build in time in our professional lives to recover. Spa days, a round of golf, or a weekend getaway can ultimately help us reach higher levels of success.

4. Take Risks: The status quo rarely produces exceptional results. There are many elite athletes who have taken enormous risks to achieve success. For example, there are many professional football players who have changed positions (from offense to defense) when entering the league in order to make the team. An undersized college wide receiver may in fact make an excellent cover corner or safety in the NFL. Some of these players have gone on to become hall of famers and excelled for many years in their new positions. In medicine, as well as in many other professions, we must often go outside of our comfort zones in order to reach the next level. Pushing ourselves allows us to improve the care that we provide to our patients. We may learn about and master new procedures or therapies and in turn be able to offer these to our patients.

I continue to be inspired by amazing athletic performances. Elite athletes can teach us a great deal about success. These exceptionally gifted humans are able to perform amazing works on the field of play. Much of what makes them so successful is hard work, dedication and perseverance. The way in which athletes train can be applied to our daily lives and can in fact, make us more effective. As physicians and providers of healthcare, we must adopt some of the skills that make these athletes successful and strive to provide elite level care to our patients. So, I guess this has been our pre game pep talk for the day. Now, grab your stethoscope, strap on your white coat and let’s go out there and “win one for the Gipper!”


Courage to Care for the Dying: The Importance of The Art of Palliative “Caring”

As healthcare providers we are focused on Life.  We are committed to healing.  We measure success by lives saved.  Unfortunately, many diseases remain incurable.  Some diagnoses do carry with them a death sentence in spite of the best that modern medicine has to offer.  Even in theses extremely devastating cases, WE can still make a huge difference in the lives of our patients in the way in which we help them handle their own death.  Too often, treatments are prescribed which may have the effect of only prolonging suffering.  In some experimental chemotherapies, treatment may raise survival only a few percentage points.  As caregivers, we become so focused on changing the inevitable outcome that we often forget about one of the more important reasons we are treating our patients–to ease pain and suffering.  In the case of terminally ill patients, we can help shepherd them through the process of death.  Too often, however, we as healthcare providers are ill-equipped to tackle this task.

Last week in  New York Times, author Abby Goodnough chronicles the hospice care death of Martha Keochareon who happened to also be a nurse.  As described in the Times piece, Ms Keochareon, during her final days,  heroically wanted to help other nurses understand how to care for the dying.  She reached out to her former nursing school and asked if there were students who needed to do a case study for class.  She volunteered to have them come to the house and learn about hospice care–what she taught them was so much more powerful.  The students began to learn what is most important to the terminally ill patient.  Ms Keochareon taught them the importance of a gentle touch, of listening, and most significantly, taught them how to truly care for a patient facing inevitable death.   Too little time is spent understanding death and dying.  The selfless act of Ms Keochareon opened the eyes of young nursing students–in effect, the time they spent with her made them better caregivers.

As a whole, medical education for both physicians and nurses lacks formal training in dealing with death and dying.  There is little standardized palliative care training in the Residency curriculums of most programs in the US today.  Although some programs do provide a palliative care experience, many do not.  Learning from a palliative care expert and from experiences with terminally ill patients can be a career changing experience.  No matter what specialty a healthcare provider ultimately decides to focus on, all of us must deal with death and dying in one way or another.  HOW we deal with death, may impact our patients in ways that are just as significant as performing a life saving operation or providing other life saving therapies.  When patients enter into the phase of their disease where death is inevitable, quality of life, quality of interpersonal interactions and quality of companionship often become incredibly important.  As a resident at the University of Virginia, I had some exposure to an inpatient hospice unit.  Although it was often sad to see patients slip away, my experience there made a huge impact on my development as a physician.  In my residency experience, I had the benefit of watching the interactions and care provided by experienced hospice nurses and physicians.  The thing that affected me the most was the concern in the eyes of the caregivers–the connection that each of them made with their patients.  Gentle touch–carefully timed smiles–and non verbal communication through caring glances seemed to make enormous impacts.

Ms Keochareon inspirational story can teach all of us something about the process of dying.  To learn, we just have to open ourselves up to our patients and carefully listen and observe.  Even in her death, she intended to give to others.  She opened the eyes of young, impressionable nursing students.  I suspect that those students are better for having known her–even if just for a little while.  Rightly so, we are all trained to focus on the cure and to strive to make our patients well.  However, we must not forget about patients when they approach the other end of the spectrum.  It is our duty to guide our patients as comfortably and gracefully through the process of death and dying as well.  As healthcare providers, we must all work to perfect the “art” of caring–even at the very end of life’s journey.

Holding Hands with Elderly Patient

Carpe Diem: The Importance of Routine Office Visits

As I have written many times in my previous blogs, it is essential that patients and physicians partner in the management of disease.  Outcomes are improved when patients are actively engaged in their own healthcare.  Part of engagement involves forming a relationship with a physician through regular follow up visits.  Relationships with doctors, just as with friends and spouses, evolve over time.  Trust and communication skills are built through recurrent contact and interaction.  Recently, a large meta analysis performed by the Cochrane group was published and concluded that routine office visits with a primary care physician had no impact on patient outcomes.  Although there was an expected “buzz” in the national press concerning these findings, a closer look at the analysis demonstrates why these conclusions may not be entirely valid.  As a cardiologist, I struggle to increase compliance in my patients.  One of the most successful ways to improve my patient’s health and prevent cardiovascular events is through routine office visits.  I can only imagine what it must be like for internists, family physicians and other primary care doctors–office visits not only allow for treatment of chronic known disorders but also provide opportunities to screen and prevent other diseases from occurring.  I would argue, in contrast to the Cochrane analysis, that the routine office visit may in fact be the most cost effective therapy in medicine today.

This week, in response to the Cochrane publication, an article was published in the New York Times on the importance of primary  care office visits.  Author Dr. Danielle Ofri points out that each and every office encounter is an opportunity to make a difference with her patients.  Often, a patient will come in with one complaint and leave having had another diagnosis made.  Sometimes these diagnoses can be minor and other times diseases that could ultimately be life threatening are made.  The point is, through an office interaction, patients are screened and examined.  “Silent” killers such as hypertension are discovered and treatments are provided.  Moreover, a relationship is built and patients and physicians can become partners and friends.  Office visits create opportunity.  If there are no routine opportunities then the only time that patients are seen is when disease is present and manifested.  There is also a real benefit to developing a doctor-patient relationship before the patient gets sick.  Difficult decisions sometimes have to be made when one is critically ill–it is nice to be able to make those decisions with someone you trust and have known for a long time rather than with a complete stranger in a white coat.  

Now, more than ever, we must be good stewards of heatlhcare dollars.  We must carefully decide when to test, and what treatment to use.  We must avoid unnecessary testing and we must use proven therapies that have lots of evidence to back up their effectiveness.  However, eliminating routine interaction between doctor and patient is NOT the way to cut costs.  I would argue that this maneuver, while it may save money in the short term, will ultimately drive costs even higher.  Medicine is built on relationships.  A gentle touch of the hand, a smile, a nod.  Like old friends meeting for coffee, an office visit is a good time to ask about family, children, and grandchildren.  Many of us go into medicine because we like to interact with other people.  A keen observation or a comment made as an aside may provide clues for an astute physician to ask more pointed questions and make a potential life changing diagnosis.  Taking these interactions away and using pooled data derived from database dredging to minimize their impact cheapens the art of medical practice.

So, office visits are essential to providing quality care.  It provides opportunity for impact.  As a physician, a patient encounter is a chance to make a difference. Use each encounter to its fullest potential.  Seize the Day.  


Tips for Keeping New Year’s Resolutions: Don’t Let The Supermodels Derail The Train

Almost 50% of Americans make New Year’s resolutions.  The most common resolutions include weight loss (through dietary changes and exercise) and smoking cessation.  As the New Year begins, many gyms and fitness clubs are filled with new members.  Many of us begin the year with the best of intentions.  However, by the end of January only 66% of people will continue their resolve to work out and lose weight and by June that number drops to only 44%.   Even with these high attrition rates, research shows that people who make resolutions are 10 times more likely to succeed as compared to those who do not.  Many dieters and new fitness enthusiasts use pictures of models or a pair of “skinny jeans” as motivation to work out and commit to change.

Interestingly, this week on NPR I listened to a program about the effect fitness models and visual stimuli may have on our ability to lose weight.  Researchers in the Netherlands studied two groups of people with goals of losing weight.  Both groups were given diet and exercise logs in which they were to record a food diary and chronicle their exercise activities.  One group’s logbook had pictures of attractive models in swimsuits on the cover and on nearly every page.  A second group was given a logbook with only a logo or no picture at all.  The subjects were studied over a period of months.  Although at the outset of the study, both groups did about the same, as the study continued, the performance of the two groups began to diverge.  Quite surprisingly, the group without the skinny, attractive models on the pages of the logbook significantly outperformed the other group.  The group that had to contend with pictures of the skinny models on every page tended to exercise less, cheat on the diet recommendations and ultimately many actually gained weight.  The researchers hypothesized that the group confronted with the skinny, attractive model each and every day tended to feel that their goals were unobtainable and ultimately “gave up”.  

So, what can we do to improve our chances of keeping our New Year’s resolutions?  Like many health experts I want my patients to succeed and reach their 2013 goals.  In order to make resolutions stick, I suggest the following 5 keys to success:

1. Set realistic goals:  As evidenced by the recent study discussed on NPR, even subliminal suggestions to obtain a “perfect” model like body can be detrimental to success.  Set small, interim step wise goals and work up to bigger, tougher ones.  Give yourself a reasonable time period in which to obtain your goals.

2. Plan ahead:  Too often we focus on the goal and not the path to achieving the goal.  It is important to spend time planning a diet and workout regimen and realistically determining how much time and money you can spend on achieving your goal.  

3.  Reward yourself:  When you achieve a small or interim goal, reward yourself.  Take in a movie with a friend, schedule a massage or some other enjoyable activity. After meeting an interim weight loss goal, go shopping for a new size!  Positive reinforcement works.  

4. Get support:  Particularly with diet, exercise and weight loss, there is strength in numbers.  Develop a buddy system.  Hold each other accountable for the achievement of goals.  When things get difficult, often a quick phone call or a word of encouragement from your buddy can make a huge difference.

5. Anticipate slips:  Change is hard and does not occur without a struggle.  It is only natural that during your journey to better health, that you slide back into old habits from time to time.  Plan ahead on how to deal with setbacks.  How you respond to a setback can determine your path to success.

As evidenced by the study featured on NPR this week, unrealistic goals can derail our ability to be successful with New Year’s Resolutions.  There is no “perfect” body type and no ideal body shape or size, despite what our society dictates.  We must individualize goals and strive for improved health–ultimately that is the best measure of success.  Society will always attempt to determine what is acceptable and what is not–we must work to see  beyond these false and often artificial standards and do what is best for ourselves and our patients.