Tag Archives: medical profession

Academic medical centers: Education or profits?

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The quality of health care depends on many things, but certainly medical education is uniquely significant. Following four years of medical school, the additional years of internship, residency, and fellowship are not simply a time for acquiring the latest insights into the nature and treatment of disease. This is when fledgling doctors imbibe the values and priorities of the medical profession from the attending physicians who mentor them. If attendings have no time to mentor the doctors they are presumably training, the quality of doctors who emerge from such a system will suffer. And if the priority of an academic medical center is to increase profits rather than care for patients, patients will also suffer, first at the hospitals associated with these centers and later as patients of the doctors who trained there. The decline in the residency system for training doctors is the subject of Kenneth M. Ludmerer’s Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.

From mentorship to profits

Sir William Osler established his ideal of medical training at Johns Hopkins Hospital in the 1890s. The guiding principle was that doctors should learn to care for patients under the close supervision of highly experienced attending physicians. Right up to WWII, the highest priority of teaching hospitals remained education. Faculty members formed intense mentorships with their students, often lasting a lifetime. Lara Goitein, in an essay/review of Let Me Heal, writes: Read more

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US healthcare: Atul Gawande has some good news

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Back in June of 2009, when Congress was just beginning to formulate and debate the Affordable Care Act, Atul Gawande wrote an article on the rising (and exorbitant) cost of US health care. He focused on how waste contributes to cost — not just the usual fraud, high prices, and administrative fees, but unnecessary care: Drugs that are not helpful, operations that do not make patients any better, scans and tests that not only have no benefit, but often lead to harm. Waste accounts for a third of health-care spending. More disturbingly, it can cost people their lives.

Gawande used the town of McAllen, Texas to illustrate his case. McAllen had one of the highest costs in the nation for Medicare — twice as high as El Paso, another Texas border town with similar demographics. And it’s not as if patients in McAllen were receiving better care. Compared to El Paso, patient care was similar or worse.

It turned out that many specialists in McAllen had financial stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital. One local doctor told Gawande: “Medicine has become a pig trough here. … We took a wrong turn when doctors stopped being doctors and became businessmen.” Read more

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The patient with a list of questions

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When I want to know more about a medical condition, my first Internet destination is the Mayo Clinic’s website. It seems both reputable and decidedly non-alarmist.

Each condition is organized into a series of information packets: definitions, symptoms, causes, risks. There’s invariably a section called “Preparing for your appointment.” Without fail, it recommends that you make a list of your symptoms. Here’s an example:

Before your appointment, make a list that includes:

  • Detailed descriptions of your symptoms
  • Information about medical problems you’ve had in the past
  • Information about the medical problems of your parents or siblings
  • All the medications and dietary supplements you take
  • Questions you want to ask the doctor

Once you’ve begun interacting with your doctor, it can be easy to forget something you’d intended to ask.

I was somewhat surprised, then, to learn that some doctors are decidedly irritated when a patient brings a list to an appointment. Dr. Suzanne Koven discusses this in a Perspective piece in NEJM: The Disease of the Little Paper. Read more

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Reading Notes #1: Health care inequities. Overdiagnosis. The Doctor/Patient Relationship

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What follows are items I found interesting in magazines I’ve recently read. Normally I would have tweeted these links, but since I was on vacation from Twitter (see My Twitter vacation), I decided to create a type of blog post called Reading Notes (see Blogging and my Twitter vacation).

The bulleted titles below link to the specific item. There’s more detail on the articles I mention under References. OA indicates open access. $ indicates a pay wall. Note that emphasis in quotations has been added by me. Read more

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For U.S. health care, some are more equal than others

death-rate-after-surgeryThe Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).

We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:

  • The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”
  • Read more

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The general health checkup: Its origins, its future

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

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A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling. Read more

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The Dreams of the Founders of Family Medicine

Marcus Welby MD on the phoneLaurence Bauer has been an ardent, longtime advocate of family medicine. Among other things, he is Chief Executive Officer of the Family Medicine Education Consortium, a not-for-profit corporation that encourages and supports collaboration among Family Medicine Residency Programs and Departments of Family Medicine.

Larry and I met thanks to our mutual interest in Marcus Welby, MD. The practice of medicine has changed dramatically since Dr. Welby inspired doctors to become practitioners of family medicine. Yet each time I talk to Larry, I’m reminded of today’s dedicated students and physicians who want to practice comprehensive care with the same concern for the whole person that Welby expressed for his patients. This remains a timeless value of the medical profession, and for Larry, it’s important to keep that value alive in an age of narrow subspecialties and corporate medicine.

Family Medicine as a specialty (a three-year residency after medical school that includes the study of internal medicine, pediatrics, obstetrics-gynecology, psychiatry, and geriatrics) emerged in the late 1960s. Those who initially endorsed family medicine wanted to change the direction of medical culture and influence its future. In the words that follow, Larry addresses those early visionaries. I’d like to thank him for allowing me to share his thoughts.

The Dreams of the Founders of Family Medicine

When poetry strays too far from music, it atrophies. When music strays too far from dance, it atrophies – Ezra Pound

As Family Practice emerged from the field of General Practice, it is important to realize that many in and out of medicine told the founders they would not succeed. The cynics believed that the dominant forces in medicine were too entrenched and there were too many societal forces working against the idea of a generalist renaissance in medicine. “Real” medicine of the future aspired to something more worthy. Real medicine involved care of hospitalized patients and was informed by the scientific and technological advances associated with sub-specialty medicine. Anyone could care for the people “out there”. But the founders dreamed big, bold dreams; they were a determined and visionary group. Read more

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Is a liberal arts education good preparation for being a doctor?

Dr. Joel AngI’ve written before about doctors and the arts. In 1980 the cultural historian G. S. Rousseau, citing the techo-scientific nature of modern medicine, claimed that doctors no longer maintained the rich tradition of physicians as humanists. “Until recently, physicians in Western European countries received broad, liberal educations, read languages and literature, studied the arts, were good musicians and amateur painters; by virtue of their financial privilege and class prominence they interacted with statesmen and high-ranking professionals, and continued in these activities through their careers.”

Contemporary evidence contradicts Rousseau’s claim that physicians are no longer practitioners and connoisseurs of the arts. We may not personally encounter a doctor with her cello or recognize one painting en plein air in the little free time doctors have these days, but doctors write books that ascend the best-seller list, and many more write thoughtful, provocative blog posts. The poetry of doctors is published in medical journals and is available online in modest chapbooks. Nearly every major city throughout the world has an orchestra staffed by the medical profession. And the American Physicians Art Association encourages and assists physicians with art organizations and exhibits.

Is a liberal arts education valuable to physicians?

I have many unanswered questions about doctors as practitioners of the arts. I’d particularly like to know if the long-standing tradition of physicians as humanists has changed over the past half century. Higher education has definitely changed since the mid-20th century. In particular, there’s less emphasis on the value of a liberal arts education. (On this, see the excellent book, Not For Profit: Why Democracy Needs the Humanities, by Martha Nussbaum.) Has this affected physicians, either in their satisfaction with their careers or in their understanding of patients? Read more

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Why is it so hard to reduce US health care costs?

Why is it so hard to reduce US health care costsProfessor Victor Fuchs and Dr. Arnold Milstein, both of Stanford University, have an article in a recent issue of The New England Journal of Medicine that asks: Why is it so difficult to reduce health care costs in the US? The article is available in its entirety online, but for those short of time, here’s a concise (and depressing) summary.

The graphic accompanying the article is dramatic in its simplicity. Health care spending in the US is 17% of GDP. In other developed countries (Western Europe, Canada, Australia), the number fluctuates around 10%. And yet life expectancy in the US is the lowest of these countries – almost four years below that of the number one country.

We know that some physicians and health care providers manage to operate at less than 20% of the average cost of care, without sacrificing quality. If everyone followed their example, the US could save $640 billion a year (US health care costs for 2008 were $2.3 trillion). Why doesn’t that happen, or as Fuchs and Milstein put it: “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer comes down to perceptions and behaviors. Read more

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Pascal Bruckner on doctors and patients

Doctor patient relationshipA concise summary of the history of the doctor-patient relationship: It began with reverence and respect for the physician, changed dramatically in the 20th century, is in an unhappy state today, but may aspire to something more satisfying in the future. (emphasis added)

There is no figure more ambivalent than the doctor, who is simultaneously a preacher, a magician, and a healer, the master of both life and death. For a long time the image of him oscillated between two extremes: that of an arrogant practitioner intoxicated by his power and endowed with all the attributes of knowledge; and that of the family doctor, the tutelary divinity of French society who knew how to combine sound, precise diagnosis with friendly advice about what to do. …

Everything changed when medicine became specialized and liberalized. In the hands of a specialist, not only is the human body fragmented, but each part of it is subject to competing authorities. The result of this new status is that in dealing with a physician we oscillate between faith and absolute suspicion. Since he is supposed to know everything, a doctor has no right to be mistaken. … The contemporary patient is a skeptic who does not believe in any treatment but tries them all, combining homeopathy, acupuncture, sophrology, and allopathy, a little like new converts who embrace several religions to increase their chances. Read more

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What gets lost in the bureaucratization of medicine

Medical practice as an artIn a recent issue of JAMA, Dr. Michael H. Monroe recalls how medicine has changed in the mere 14 years he’s been practicing. His desk has a drawer on the lower right where – at the start of his practice — he began collecting articles and stories on the medical humanities and the art of medicine. Over time, that drawer has fallen into neglect.

Addressing a mentor who retired shortly after he began his own practice, Dr. Monroe writes: (emphasis added)

A 14-year career of rounding, teaching, and publishing has not the longevity you had at your “retirement,” but it feels like it’s become an increasingly wearying few years. Concerns of coding, billing, documenting, administration, computers, surveys, rules, regulations, and politics have increasingly occupied my mind and space like an intracranial tumor, slowly compressing my right hand drawer. …

Medicine today is science, and business, and law (perhaps not in that order) but not so much art as it seemed to be even when I started. It is a world of statistics, evidence-based medicine, and quality improvement; of increasing things to count, to codify, and to structuralize. I know why we are counting, why it is important, essential even, and we are doing better, say the numbers, and I mark the progress but still can’t shake the feeling that in medicine, things easily counted need to be distrusted. Despite years of study and numbering, after all, we still haven’t settled the role of vitamins, hydrochlorothiazide, mammograms, aspirin, diabetes control, or almost any other topic in medicine including statistical analysis itself. What I have slowly realized and come to reluctantly is how hard it is to prove that anything is true. … Read more

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The emotional burdens of patient care

The emotional pain of doctorsIn a recent issue of JAMA, Dr. Michael Stillman writes about the emotional pain of delivering bad news to a patient he has known through the best and worst of times.

Earlier in my career, delivering bad news seemed like a technical challenge. I would methodically seat patients and their family members facing one another, pause for a moment after reporting that there was an “unexpected finding” on a scan, and search for an opportunity to say that I “wish things were different” and that I would be there to help until the very end. This routine, though slightly stiff, helped anchor me in whatever emotional swell was to come.

Now, however, these conversations just make me sad. …

Patients suffer and die, and a physician must find the balance being feeling her own humanity and maintaining the professional stance that allows her to move on. There are no simple guidelines, although Dr. Stillman suggests remembering the good times his patients have had and focusing on those moments.

Emotional hazards of practicing medicine

I wonder just how aware patients are of the psychological burden of being a doctor. Dr. Stillman writes:

I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many “civilians” would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.

How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction? …

There is simply no way to be a good but distant physician.

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From healthism to overdiagnosis

H Gilbert Welch OverdiagnosedIn his new book, Overdiagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch enumerates how the cutoff points that determine whether a patient should be treated for a disease – diseases such as high blood pressure, diabetes, osteoporosis — have been creeping inexorably lower over the years.

Take diabetes. The cutoff point used to be a fasting blood sugar level of greater than 140. In 1997, the number was lowered to 126. This immediately created 1.7 million new diabetes patients.

In a highly publicized study that began in 2003, one group of patients with type 2 diabetes received “intensive therapy” to make their blood sugar “normal.” The control group – the other half of over 10,000 patients – received treatment to lower their blood sugar, but not to the new normal level. The trial was stopped in 2008 when it became clear that there was about a 25% increased risk of dying for the intensive therapy group.

Dr. Welch’s comment on this: “If it’s not good to make diabetics have near normal blood sugars, then it’s not good to label those with near normal blood sugar diabetics. Why? Because doctors will treat them. People with mild blood sugar elevations are the least likely to gain from treatment – and arguably the most likely to be harmed.”

High blood pressure (hypertension) was also redefined in 1997. Instead of the cutoff points being 160 systolic over 100 diastolic, the numbers dropped to 140 over 90. This created 13.5 million new patients.

The definition of high cholesterol (hyperlipidemia) changed following a 1998 clinical trial. The definition of “abnormal” total cholesterol fell from 240 to 200. This created 42.6 million new patients, an increase of 86% over the previous number of patients.

It’s the same with the definition of osteoporosis. A bone mineral density X-ray produces a T score. It’s a way to compare an individual’s bone density to what’s considered “normal.” For women, normal is defined as the bone density of an average white woman aged 20 to 29 (a T score of zero.) If your T score is less than zero, it’s assumed you have an increased risk of fracture.

In 2003 the definition of osteoporosis changed from having a T score less than -2.5 to less than -2.0 (i.e., closer to normal). This created 6.8 million new patients, an 85% increase in those now eligible for treatment with drugs that turned out to have significant side effects – as virtually all drugs do. Read more

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Megan McArdle: Why are there no new antibiotics?

Approached by the Antibiotic ResistanceMegan McArdle spoke on antibiotic resistance at the Economic Bloggers Forum yesterday. McArdle is a journalists who writes for the The Atlantic, primarily on economics, finance, and government policy.

Her presentation, “Antibiotics: The world’s most broken market,” was interesting. Notice (in the video below) that she never questions the market-driven premise of pharmaceuticals – and by extension, the for-profit nature of medicine and health care. That’s not her politica/economic persuasion.

Here’s an excerpt from the talk where she discusses the patient/doctor end of the antibiotic resistance problem. What she says is already quite familiar. What’s interesting is her frank description of how doctors behave and how patients in turn regard doctors.

People love to get antibiotics. They go to their doctor and they’re like, “My kid has an earache. Give him antibiotics.” Now the doctor could say, “No we shouldn’t. We should wait and find out if it’s bacterial. Almost all ear infections are bacterial. Due to throat infections. Due to almost anything you can name. But to do that, the doctor has to sit down and deal with an angry patient who may pick up and leave their practice.

If you look at the way that the current insurance industry is organized, right, what do doctors need? They need volume. They get paid by volume. Reimbursements for primary care physicians, who are where a lot – by no means all – but where a lot these vaccines go through, are very low. They’ve made up for that, and you all know this, right. You go into your doctor, and the minute you start talking, your doctor exudes an almost visible — like — desire for you to leave now. So that they can go on to the next patient. So what do they do? They give antibiotics to patients to shut them up. It takes too much time to explain and the risk of losing the patient is high.

Where have all the unattractive people gone?

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Are the most heavily marketed drugs the least beneficial?

Prescription drugs symbolIn a perfect world, doctors would not prescribe – and patients would not take – drugs that do more harm than good. But it’s complicated. The benefits and harms of drugs are determined in randomized, controlled clinical trials. For many reasons, the outcomes of such trials may not provide doctors with the information they need to decide who should take what.

For example, harmful effects (like death) may not show up during the limited time span of a trial. Data from trials may be selected – and other data ignored — to produce positive results. This is apt to happen when clinical trials are conducted by the pharmaceutical industry, rather than by economically disinterested parties, such as the NIH or independent academic institutions. Also, the participants in the trial may differ significantly (in age, gender, and health, e.g.) from patients who end up taking the drugs. As a recent article in JAMA put it, “most clinical trials fail to provide the evidence needed to inform medical decision making.”

The Inverse Benefit Law

If you follow pharma news, you will have noticed that many high profile, aggressively marketed drugs turn out to be either ineffective or positively dangerous (think Vioxx, widely prescribed for arthritis, which turned out to cause heart attacks and stroke). Howard Brody, MD, and Donald Light, PhD, have proposed an explanation for this phenomenon. They call it the Inverse Benefit Law: “The ratio of benefits to harms among patients taking new drugs tends to vary inversely with how extensively the drugs are marketed.” Or (for those who feel fuzzy about inversion): The more aggressively a drug is marketed, the more likely the drug will cause harm, be ineffective, or deliver little by way of benefit. Read more

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Complaints about pharma go way back … to ancient Rome

History of pharmacyOne hundred years ago, editors of The Journal of the American Medical Association voiced their complaints about “pharmaceutic” problems. In particular, they objected to proprietary remedies (compounds with secret formulas), the inappropriate substitution of one drug for another, counterfeit drugs, and flowery but meaningless names that served only to increase the popularity of a drug.

According to the anonymous editors, these practices were in fact nothing new, but could found in descriptions of the ancient Romans.

Pliny the elder (first century AD) complained that physicians of his time used remedies that had already been prepared, thus saving the time it would take to prepare them. A historian (Ludwig Friedlaender) writes of the Romans: “[O]ften the physicians did not know the exact ingredients of the compounds that they used and should they desire to make up written prescriptions, would be cheated by the salesmen.”

Pharma reps less than totally forthcoming? Hmmm.

In the second century AD, Galen also complained of physicians who used “ready-made” medicines. Both Galen and Pliny believed prescriptions should be carefully prepared by physician’s themselves, or at least under their close supervision. But no. Some doctors simply followed the line of least resistance and abdicated this most important function. Surely this brought harm to both patients and the physicians themselves. Read more

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Doctors eliminate the middle man: Insurance

Doctors practice outside insurance systemIn Seattle, Washington, a group of 12 physicians and nurse practitioners see patients at a clinic that doesn’t accept insurance. Instead, patients pay roughly $65 a month, every month. In return they get unlimited office visits (including evening and weekend office hours), e-mail and phone access to practitioners, and – my favorite part – appointments that last up to an hour.

There are some additional charges, such as for lab work and other outside services, but these are billed at or near cost, and many medications are available at a discount. Even if you add in the cost of catastrophic medical coverage – say, $225 a month – this is still a reasonable price to pay for health care, especially compared to the premiums charged these days by major health insurance companies.

The real beauty of the plan, however, is not only that it’s attractive to patients. It can be a way for struggling primary care physicians to maintain a financially viable practice. The average patient pays $700 to $800 a year for membership. According to a report from Kaiser Health News, this is three times more than a doctor makes for each patient in an insurance-based practice. Not to mention the extra time and the absence of aggravation that comes when doctors eliminate insurance companies.

Norm Wu, president and chief executive of Qliance Medical Management, the direct-pay practice in Seattle, comments:

“So we can have a third the number of patients and get the same revenue per clinician, but with much less overhead.” … The approach, he says, allows Qliance to funnel more money into the care itself — through longer office hours, for example, or better diagnostic equipment.

A patient at Qliance comments: “The doctors will sit there with you as long as you need them to. … They don’t rush in and out.”

Lower costs and no complaints

Direct-pay primary care was encouraged in Washington by a new state law in 2007. The law permits direct patient practices – also called retainer health care – to operate without some of the legal and financial requirements typically imposed on entities such as insurance companies and HMOs. The goal of the legislation was to provide more affordable care for patients, improve access to primary care, and reduce the use of emergency rooms for primary care purposes. Read more

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Surgery at a deep discount

Tummy tuck and medicine as a for-profit businessMedicine is a profession. Economically, it’s sufficiently different from other marketplace transactions that it shouldn’t be run as a for-profit business. When I made that argument in a recent post, I mentioned: “The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.”

That may still be true of brain surgery, but it’s obviously not true of plastic surgery. Here’s an excerpt from a recent press release:

Though the recession is slowly lifting, desired cosmetic surgery is still out of reach for some. And with winter almost over, time is running short for those who want to receive plastic surgery in time for summer. That’s why Dr. Lapuerta of the Plastic Surgery Institute of Southeast Texas, sympathetic to both his patients’ time and finances, is offering a very special offer of $500 off the very popular surgery, tummy tucks.

Just to make sure you understand how sympathetic Dr. Lapuerta is, the release continues:

With cosmetic procedures slowly but surely on the rise, Dr. Lapuerta wants to ensure that those who desire the procedures are more able to attain it. He appreciates the present circumstances stating, “I know that a tummy tuck or any cosmetic surgery can seem out of reach of many. Even though the procedures are on a rise, a lot of people who want the surgery are unable to get it because of finances. I hope that offering this special deal will help.”

Guess he doesn’t offer financing. According to Laurie Essig’s American Plastic: Boob Jobs, Credit Cards, and the Quest for Perfection, 85% of cosmetic surgery is purchased on credit and over 70% of patients earn less than $60,000 a year. Read more

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From MD to MBA: The business of primary care

Business of primary care physicianYou could argue that medicine was never meant to become a for-profit business the way selling cars, cosmetics, and fast food are businesses. Among the differences between being a patient and being a consumer of non-medical goods and services:

  • There’s an asymmetry in the knowledge available to patients and doctors – a patient can’t possibly be as informed as a doctor about what’s wrong and what’s needed.
  • Patients can’t predict when they’ll need medical care and often seek care when their health is threatened and when decisions must be made quickly.
  • It’s the supplier – the doctor – who determines what the patient needs.
  • There’s an ethic that assumes doctors will not sacrifice the medical needs of a patient to make a profit.
  • There’s a very steep entry cost to becoming a doctor.
  • The health care market is basically not price competitive – a patient contemplating brain surgery is not going to be tempted by a surgeon offering a deep discount.
  • What’s at stake in health care – the consequences of making a mistake – is death and disability, not simply a case of buyer’s remorse.

And yet, in the United States, health care has become a for-profit business. The story of how this happened is complex, but decisive elements include the advent of Medicaid and Medicare in 1966 and the widespread availability of employer-sponsored health insurance, which got a boost during the wage freeze of World War II. Once patients no longer needed to know the true cost of health care, business interests were free to create what Dr. Arnold Relman called the “medical-industrial complex.”

Regardless of how and why it happened, we now accept that medicine in the US is a profit-generating business, where many segments of the “industry” aim to reward investors, not patients. As a result, health care has become too expensive for many patients, for employers, and for the government. Everyone agrees that costs are out of control, but – with so many competing economic interests — the solution is extremely elusive.

Doctors caught in the middle

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JAMA announces new editor-in-chief

The Journal of the American Medical AssociationThe American Medical Association (AMA) was founded in 1847, a time of significant change in the practice of medicine and of intense competition among practitioners. It began publishing its peer-reviewed medical journal, The Journal of the American Medical Association or JAMA in 1883. The AMA has just named a new editor-in-chief for that journal, Howard C. Bauchner, a pediatrician from Boston University School of Medicine.

The two medical journals in the US that cover general medicine — as opposed to specialties — are JAMA and The New England Journal of Medicine (NEJM, founded in 1812). Both have their strong points. JAMA preserves the humanistic tradition of medicine. Each issue includes poetry, a personal essay, book reviews, and artwork on the cover that’s thoughtfully discussed.

It’s much more stodgy than NEJM, however, at least in my opinion. During the presidential election and then during the debate over health care reform, NEJM published timely commentaries on the issues and made them available online to non-subscribers. It continues to cover topics such as the legal challenges to the health care bill. Not only does JAMA give less space to these issues. Articles in JAMA are not available online without a subscription ($165 for 48 issues).

Reaching the general public in an online world

That may change with the new editor-in-chief. Dr. Rita Redberg, editor-in-chief of the Archives of Internal Medicine (also published by the AMA) told Reuters that JAMA faces the same issues that confront newspapers and magazines these days: “how to live and flourish in this online world.” Read more

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History of patient modesty part 2: Convincing patients to disrobe

Pelvic exam patient modestyIn part one of this post I explained how a new anatomical understanding of disease in the 19th century changed the practice of medicine. Prior to this insight, there was no need to expose the naked body to observation or to touch parts of the body that were normally clothed. In order to apply the anatomical theory of disease, doctors needed to discover what was happening inside the body. This required a new type of physical exam, with much greater exposure and invasion of the body. The new exam was an abrupt and significant change in the tradition of patient privacy and modesty.

Making patients blush

Doctors welcomed both the new understanding of disease and new techniques, such as the stethoscope, that gave them useful information about the interior of the body. Understanding and technique alone did nothing to improve the ability to treat disease, by the way. That came much later. What doctors could do was provide a better prognosis, thus avoiding futile and painful treatment of the terminally ill.

How did patients react to this change in medical practice? Unfortunately, we have very little direct information. Most of the evidence we have comes from doctors, not patients. Doctors tend not to record the routine and taken-for-granted nature of a patient encounter. The private diaries of patients undoubtedly recorded reactions to the more invasive physical exam, but historians of medicine have typically been more interested in uncovering evidence of new medical discoveries than in noting patient experiences.

There is every reason to believe that women found the new physical exam deeply embarrassing. For example, a woman’s diary entry from 1803 reads: “Doctor Williams called and made me undergo a blushing examination.” In 1881, Conan Doyle recorded that a female patient would not let him examine her chest. “Young doctors take such liberties, you know my dear,” she told him.

The indirect evidence we have comes from efforts of the medical profession to convince patients that the new physical exam was necessary and proper. This took two forms: Emphasizing the professionalism of doctors and arguing for the scientific nature of medicine. These 19th century changes in the image of medicine contain the seeds of a new relationship between doctor and patient. They led to a style of medical practice today that increases rather than eases patient concerns about privacy and modesty. Read more

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Why are there so many cosmetic surgeons?

Cosmetic surgery Dr. 90210Well, one reason is that primary care physicians are being financially squeezed out of practicing their profession. There’s a good post at KevinMD on how physicians are responding, along with an acknowledgment of this sad truth in the comments. The post is called “Primary care physicians are rebelling against the system.”

Here’s one comment that explains why more doctors are doing cosmetic surgery:

Great article, I agree this is a quiet and insidious rebellion. I found myself dropping one insurance after another, adding more and more cash based ancillaries, until my practice is now 99% cosmetic (botox, laser, etc.) and 1% internal medicine. My next decision is whether to bother spending the time and money to recertify in internal medicine this year. I probably will not. Sad situation for medicine in America, but the reality for most of us.

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History of patient modesty part 1: How bodily exposure went from unacceptable to required

Patient in open-back gownEven doctors can be embarrassed when it comes time to expose their private parts to medical personnel. In an essay that appeared in The Journal of the American Medical Association, a doctor describes her discomfort as she arrives for a colonoscopy appointment.

[A]s a person not exactly looking forward to the morning’s adventure, I found the receptionist’s demeanor and lack of eye contact wrapped me tight within a cold, impersonal cocoon. I was a subject. Though I hadn’t shared my sentiments with anyone, I felt both vulnerable and completely sheepish about having a very human reaction to such a common procedure. But this was my bottom and I was not happy to share it with others. Here to be exposed and invaded, in truth I was embarrassed and sought compassion. As anyone else would, I wanted to know that my discomfort, self-consciousness, and loss of control were understood. Instead, she exuded efficiency and delivered transparent quality assurance and poise.

The need to reveal private and intimate parts of our bodies is a routine occurrence in medical practice today. Though it may offend our modesty, we take it for granted that the embarrassing moments of a colonoscopy, a Pap test, or a prostate exam are necessary for our health.

Has it always been so? Have doctors always expected patients to disrobe? Have young male technicians always exposed the chests of female patients in need of a routine EKG? Have patients always been willing to allow doctors and their staff to view parts of the body normally seen by only the most intimate of partners? Read more

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Out of Practice: The demise of the primary care practitioner

Out of Practice Frederick M BarkenThe business of practicing medicine has not been good for doctors over the last 30 years. A post of mine called “Are doctors tired of practicing medicine,” on a site for primary care physicians, elicited the following complaints.

  • Doctors are no longer doctors, but poorly paid employees of the health insurance industry.
  • Without changes in how we treat doctors, more will retire early and med students won’t opt for primary care.
  • Everyone in the system is unhappy, obnoxious, or unsupportive, not just the doctors.
  • Maintaining electronic health records has a higher priority than caring for patients, and the effect on morale is disastrous.
  • The work doctors once did has been taken over by nurses, NPs, PAs, and hospitalists. We saw it coming, so we have only ourselves to blame.
  • No time for patients and too little reimbursement is extremely stressful.
  • Students these days prefer “lifestyle” specialties that pay well and give them nights and weekends off.
  • Even though you may love what you do, paying off med school loans lasts way too long, and that’s frustrating.
  • Despite modest financial ambitions and a strong motivation to help people, “managed care medicine really killed the doctor in me.”
  • This is not what doctors signed up for.
  • Interruptions, time pressure, low pay, high overhead, unrealistic expectations – who needs this?
  • We are not tired of practicing medicine … WE ARE EXHAUSTED.

There was not one response from a happy and satisfied physician. Read more

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Reluctant patients: The mental health of doctors

Mental health of doctorsThe British medical journal The Lancet surveyed a number of studies that discuss troubling statistics on suicide and depression among American physicians. The subject is not new, but the studies attempt to provide a few new insights.

A 2004 analysis in The American Journal of Psychiatry found that male doctors were 1.41 times more likely to commit suicide than other men. The statistic for female doctors was significantly higher, 2.27.

The cause of the increased rates is not known, but the problem seems to start in medical school.

At medical school, competitiveness, the quest for perfection, too much autonomy coupled with responsibility, and the fear of showing vulnerability have all been cited as triggers for mental ill health.

The stigma of not being able to cope

A study in JAMA published last year looked at the fear of showing vulnerability. It found that 53% of medical students who had high levels of depressive symptoms were concerned about revealing their state of mind. They felt such honesty would be risky for their careers. Many saw the mere act of asking for help as an acknowledgment that their coping skills were inadequate.

Medical students are under extraordinary demands. They feel they are making life and death decisions and that they can never be wrong. There is such tremendous pressure to be perfect that any sense of falling short makes them very anxious.

If medical students are critical of each other about depression, how does that transfer to patients? We don’t want the medical education experience to make them less tolerant of mental illness. Stigma seems to be lessening among the general public. But it is possible the medical professional is lagging behind.

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Are doctors tired of practicing medicine?

Dr. Ben Carson George BushIn the mid-20th century, physicians were among the most highly admired professionals, comparable with Supreme Court justices. … Depictions of physicians on television were overwhelmingly positive. Doctors were able to trade on this cultural perception for an unusual degree of privilege and influence.

Today, medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future.
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Screening for cancer and overdiagnosis

Screening for cancer: OverdiagnosisEarlier this month scientists announced a test that can detect a single cancer cell in a blood sample. Although some news reports were realistic – BusinessWeek commented that “researchers still aren’t sure what these circulating tumor cells (CTCs) actually mean” – most greeted the news as a revolution in the fight against cancer, promising early, non-invasive detection. Read more

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Andrew Wakfield: The integrity and validity of science

Andrew WakefieldDoctors sign their names to papers that describe clinical trials of a drug. The papers turn out to be ghostwritten and paid for by the drug manufacturer. The pharmaceutical industry buries any study it doesn’t like, creating the impression that the majority of studies are favorable to what the industry wants us to believe. Journals are biased towards the publication of studies with positive results. All of these practices greatly skew doctors’ opinions of which drugs are effective and safe. Patients die needlessly as a result, and only then does the truth come out in whistle blower lawsuits. Read more

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Mental illness in college students: Overdiagnosed

Mental health college students overdiagnosisThe sudden exploding rate of “severe” psychiatric illness on campus is most likely caused by overdiagnosis. … [T]he milder forms of the depressive, anxiety, and attention deficit disorders … are difficult to distinguish from, the commonly encountered and expectable everyday aches, pains, sufferings, and performance problems that are an inherent part of college life. Not all difficulty is disorder. Read more

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Czech doctors resign in protest

Czech doctors protest resignThe average monthly wage in Czechoslovakia is about $1200. Newly graduated doctors earn just over $866 a month. According to oncologist Peter Papp, whose salary has never broken the 20,000 koruna ($1,051) threshold, “My friends include a tinsmith, a cook. When we go out, they pay my bill. They say: ‘You are only a doctor.’ “ He earns 88 koruna an hour, or 2 koruna less than when he had a job labeling frozen chickens in his student days. Read more

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