Thursday, May 19, 2016

"Medicine may become a public health danger."

"I think we're reaching a tipping point that unless we do something medicine may become a public health danger." 

This is Ioannidis's opening line in this 5 min interview at annual Lown conference.

This is the question that most interests me- is health care, on the whole, more harmful than helpful? Is it a public health menace? If all doctors, hospitals, clinics, drugs, operating rooms, nurses suddenly vanished (along with the $2 trillion price tag), would Americans live longer healthier lives?

What does a back-of-the-envelope calculation of cost/benefit of health care look like?

I think a rough calculation would be very interesting.

If health care is so great, a rough calculation should be able to easily show it?

If a rough calculation is difficult, that argues the case that health care is at least close to being harmful (and maybe we should walk off the job?)

Monday, May 2, 2016

The Medical Bait and Switch

Image result for thinking fast and slow

I just discovered a thinking fallacy featured in the book "Superforecasting." It happens all the time in medicine.

It's called the bait and switch. It's similar to anchoring, but different.

It happens when, confronted with a difficult and foreign problem, a person substitutes an easier-to-solve and more intuitive problem, and then answers that problem. 

When someone comes to the emergency room with shortness of breath, this is a complex problem with many, many possible causes, often mixed together. Rather then get to the bottom of this, we substitute shortness of breath with a simpler problem- pulmonary edema from heart failure. Mild pulmonary edema is a much easier problem than shortness of breath. We give a relatively harmless medicine, furosemide, quantify that we're making progress by measuring its effect on weight loss or negative fluid balance, and then dust our hands of the problem and congratulate ourselves on another job well done. 

Meanwhile, while hospitalized for a few days, the patient is removed from whatever insult caused the shortness of breath (maybe the mold in their apartment triggers asthma, or the challenges of insecure housing, nutrition or basic safety, or substance use). During that remove, they feel better and their shortness of breath improves. 

They feel especially better when suggested by their doctors' leading query: "Are you feeling better?" 

This is even more effective when phrased like "You've lost a liter of fluid and your chest X-ay is clear, are you breathing better?" Who could say no?

Tuesday, April 26, 2016

Five magnitudes of medical harm

Despite the dictum to do no harm, everyone agrees that medicine is harmful. But just how harmful is it?

Level 1- The unavoidable, almost necessary harm of practicing medicine.
Example: the pain and discomfort of surgical excision of a ruptured appendix. When slicing into someone's body, causing pain and discomfort simply cannot be avoided. The benefits of surgery dramatically outweigh these travails, and so we simply soldier on. In some ways, the doctor's role is to be the authority, the stoic bearer of bad news who unflinchingly faces the facts, and disregards these unavoidable harms so that they don't impede the grisly work that simply must be done. This role was probably prominent in the early days of medicine, before anesthesia, when on the battlefield, the qualities one wanted in a surgeon were grit and speed. This level can found among retired docs and scattered about a few naive young residents.

Level 2- The enterprise of medicine is more harmful than it seems.
This level is more humble than level one. It is sensitive to the fact that mistakes and pitfalls are everywhere, and they aren't always outweighed by medicine's benefits. It knows that bad things happen just by in the hospital. Reducing this harm depends chiefly on competence, on being a good doctor. Good doctors are careful, they know their craft and try very hard to make the correct diagnoses and perform their procedures with skill. As long as the doctor is diligent, there is a certain fatalism around bad outcomes. This level is embodied by the league of residency program directors and department chairs.

Level 3- Preventable harm exists on a large scale and requires changes in the systems of care.
These were described well in the Institute of Medicine's report "To Err is Human." It detailed the massive scale of health care induced harm (hospital acquired infection, medication error, etc), far exceeding the public and most physicians' worst estimates- over 100,000 preventable deaths a year. It was recognized that medical knowledge and clinical skill had little to do with it, and that the chief drivers or mortality were in the basics-hand hygiene, timeouts before procedures, checklists for surgery. Wide scale harm is a built into the system. Change the system, reduce the harm. And the quality improvement movement was born.

Level 4- The health care system is so broken and dysfunctional that dramatic action is warranted.
This level compares the ideal of health care as a human right that society makes available to all, like education and public safety, to the reality of health care as a deeply unfair, inaccessible and expensive wealth extraction system that serves the revenue streams of multinational pharmaceutical and device companies, large insurers, and sprawling hospital systems and physician organizations. This level seeks major structural changes, such as realigning payment incentives and legislation, to better serve the underserved- the poor, the elderly, the chronically ill. The single payer movement is a prime example of level 4.

Level 5- The health care system is more harmful than helpful.
This radical fringe believes that if all hospitals and doctors' offices were eliminated, society would live better and longer lives. They see harmful corruption and misinformation in almost every facet of health care, from the faulty evidence underlying common treatments and guidelines to the delivery of health care in profit-motivated institutions. When you add up the harm from medicalization of birth and death, overtreatment of most common conditions, and society's lost investment opportunities in education, housing, and public health, coupled with the unmeasurable but devastating crisis of human dignity visited upon more than one million nursing home residents crowded into close quarters, totally dependent on underpaid staff, living out their remaining days immobile in front of a TV, it's at least plausible that these harms outweigh health care's benefit. Proponents of level 5 are mainly found on the books with titles like "We're Doomed."

Friday, December 25, 2015

Is Healthcare a Human Right?

What do we mean when we say that healthcare is a human right?

The simplest case is that we mean what the United Nations means in the Universal Declaration of Human Rights:asdf

Article 25 
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

Critics claim that "just because the UN says it doesn't make it so."

Fair enough.

For me, the reason to support the concept of healthcare as a human right requires a simple thought experiment, "What kind of society do I want to live in?"

More specifically, "How do I want my society to respond to the sick?"

It's perhaps easiest to begin by describing how I certainly don't want my society to respond. I hope it's a comfortable assumption that I speak for most Americans when I say that allowing the sick to suffer and die, unaided in the street, is abhorrent. Although there are philosophical treatises underlying this position, I think we can save some time and simply agree that callous indifference to the suffering and vulnerable is unacceptable in 2015.

The real question is not whether or not our society is responsible for the sick and vulnerable, but how responsible is it?

Put another way; it's one thing to say that indifference is unacceptable. It's another thing to compel the citizenry to act on behalf of the vulnerable.

Fortunately, we already do act, and not out of any compulsion to do so. Anywhere in this country, bystanders routinely call 911 when they witness extremis, summoning the couriers of the emergency medical system to whisk them off to an emergency room replete with all the modern tools of resuscitation. Emergency rooms treat all comers, regardless of their background, their social status, or their ability to pay This is not a small thing, and for those who can sense a righteous tone that may be building in the paragraphs to come, let me say clearly that many wonderful people execute complex care coordination to provide this essential safety net.*

Emergency services are wonderful, but health requires much more than intervening at the point of desperation. How far should our society go?

For me, a simple answer is a comparison of our education system. Any child, regardless of the neighborhood they live in, their poverty, or even their beliefs about education, gets to go to school. It is an expectation. Their is a transport system established for those who don't have access. There are support services to help parents navigate the system. There is free lunch for those who need it. The US has provided every child with a right to an education.

I think we should do the same for health. There should be an expectation that anyone who is ill, regardless of where they live or how impoverished they are, can see a doctor. If they can't get themselves there transportation should be provided. There should be services to aid navigation. Beyond acute illness, patients should have access to preventive care and social supports.

Almost every other developed nation, and even some that are underdeveloped, has this. The US does not. Unlike other nations, one's access to healthcare depends on their proximity to a clinic (community health centers are closing), on the availability of basic services in that clinic (mental health is notably lacking in primary care), on patients' ability to navigate a complex system (talk to anyone trying to understand their medicare coverage), and last but certainly not least, on the ability to pay for both insurance and out-of-pocket fees.

Simply put, healthcare is not a right for the poor and marginalized in the US.

Any discussion of rights necessarily includes a discussion of responsibility. Rights are meaningless without responsibility. The right to life is the responsibility not to kill. More than that, it is the responsibility to set up mechanisms to prevent others from killing through laws and a police force. The right to education is a responsibility not only to not interfere with another's education, but to support students with teachers and infrastructure.

We all pay taxes to support the criminal justice system and the education system. In fact, if we don't, we can be put in jail. Society compels us to pay through threat of force.

When we hand out rights, we also hand out coercion, which paradoxically amounts to taking away rights. The right to life takes away my right not to be taxed for law and order. The right to education takes away my right not to pay school taxes.

Handing out rights is more than a dreamy exercise in imprinting our vision of the world in a high-minded list. It is also handing out obligation and responsibility, collected under threat of jail time. I can understand those who are resistant to the idea of a self-selected group of idealists sitting down at a convention and deciding which obligations the rest of us have.

So, when I say I want our society to treat healthcare like we treat education, I need to make the case to those who do not want to be saddled with the responsibilities of making this a reality.

Interestingly, those skeptics often spend a good deal of time extolling the virtues of this nation, its ideals, its strengths, and its standing as a moral force in the world. They trace this virtue back to the founding fathers and the provision of rights as set forth in the Constitution. This society has become what it is, still the envy of much of the world, because of its provision of rights. Human rights serve human dignity, and human dignity is the well-spring of human flourishing.

Look what happens when we provide our citizens with education?

We can only gain by doubling down on our commitment to health.

Thursday, December 17, 2015

How I woke up to the Issue: #Blacklivesmatter

I just finished reading The New Jim Crow, by Michelle Alexander, and all I can do is wonder if there is a bigger problem, a bigger injustice, a bigger moral failing than the simple fact that Black Americans are incarcerated far more frequently for drug crimes than whites.

I verified the numbers myself. In 2013, a total of 88,500 whites were sentenced for drug-related charges compared to 117,300 blacks, according to the Bureau of Justice Statistics.1 Even though there are six times more whites in the general population, and rates of drug use are equal among whites and blacks, blacks are arrested and sentenced to prison MORE OFTEN than whites.

Like any statistic, there's more to this than simple numbers, and counterarguments and caveats are important. However, given the scale of this injustice, the burden of proof falls on those who would deny that this system is racist.

The simple conclusion is that the US drug policy discriminates according to race. If drug incarceration rates among blacks and whites were equal in 2013, then roughly 102,900 black Americans would have been spared prison.

That's 102,900 extra people behind bars, a year. That's 102,900 excess people taken away from their families, from the workplace, from their communities. That's 102,900 excess families laboring under the stigma of criminality. That's lost votes. That's lost public housing. That's lost dignity.

That's a humanitarian crisis. 

The criminal justice system is a foundational piece of our society, and it is systematically rounding up minorities and locking them in cages. How can black communities, already relegated to inner city ghettos and stigmatized by a white society, possibly reach any kind of parity in quality of life when their own government is so disproportionately heavy handed.

The book ticks off one head-shaking statistic after another, but Alexander's comparison to society's response to drunk driving is particularly compelling. In the 1980's, when drunk driving fatalities outnumbered drug related fatalities, a grassroots movement preceded a government intervention. For the population of largely white men, the focus on reforming drivers and keeping them in society resulted in a 50% reduction in drunk driving fatalities. Imagine if there was a War on Drunk Driving, stigmatizing white men and herding them into prisons by the millions while drunk driving went on unabated? 

Alexander is compelling when she traces the systematized oppression of blacks as a means to capture white voting constituencies, from the end of slavery to Jim Crow to the war on drugs and mass incarceration. 

She calls for what Martin Luther King called for, a human rights movement. 

I'm outraged, but I'm also embarrassed. How could I be an educated 36 year old physician and just now realize that I'm a tax-paying accomplice to a humanitarian crisis? We are hiding the truth from ourselves, we are deceiving ourselves. We are comforting ourselves that, since a black man is president, we are finally absolved from our legacy of oppression. 

I believe, as Alexander does, that like myself, most Americans genuinely abhor the thought of racism and would never characterize themselves as such.

If that's the case, then we have to get off our butts and do something about this. 

For a detailed look at strategy for effective engagement with this topic, please consider taking the time to read this strategy piece by the Open Philanthropy Project.

1- Appendix Table 4 page 30

Friday, November 13, 2015

Retire Early and Come Work for Me for Free: Plenty of time with patients, flexible hours, no hassles, and no documentation!

I hear it more and more- "They've taken all the joy out medicine."

According to some, doctors are retiring early (purportedly due to the Affordable Care Act). 

Job satisfaction among physicians is low and getting lower, with a survey showing most would quit if they could. The typical reasons are rehashed: stress, poor work-life balance, busy work, reimbursement, etc. But I personally think it boils down to what Mark Linzer described as the root of burnout: failure to achieve meaningful change in the world.

So, what to do with a glut of retired doctors? These are seasoned clinicians who don't have loans to pay off, and presumably are seeking a sense of joy that has been lost to the drudgery of 15 minute office visits and the bureaucracy of the patient centered medical home.

What if we set up clinics where these early retirees could volunteer their services? The promise to docs is that they would be offered everything possible to facilitate an enjoyable work day, which probably means opportunities to make meaningful change in the world, ie provide good healthcare. In exchange for having fun practicing medicine, they work for no salary.

Physician salaries represent 46% of total operating costs. Volunteer doctors would open up almost half the budget of a primary care practice to hire support and otherwise innovate to keep these doctors happy. Doctors could have plenty of time to talk with patients because there would be less pressure to maximize throughput. Each doc could have a scribe to handle documentation. There would be a full time mental health professional on site for immediate in-person referrals. A physician could be hired to take call at night and on weekends. Finally, clinicians could be spared the need to try to keep up with quality metrics in an effort to boost reimbursement (and don't reflect quality).

If volunteerism were high enough, hours could be quite low, affording docs plenty of time with family and friends.

I bet patients would love to see a senior, happy, un-hurried and un-harried doctor.

This matters to me because it matters to patients. Simply put, if doctors don't feel like they're making meaningful change in the world, then it's a safe guess that patients aren't getting good care. It's hard to conceive of a world where doctors hate their job, and yet patients are doing great. I cringe at the thought of advocating for doctors, but I think their sad state is rooted in the same systemic problems that drive patient dissatisfaction and poor health.

Changing the healthcare system is important, but it will take a while, far too long to salvage the doctors who are retiring early. Why not give them an option to make a difference?

Saturday, October 17, 2015

Fighting the Tide

Working in healthcare today feels like being caught in a riptide at the beach- all the patients are up on the sand, struggling with their health and illness, but if they want to see their doctor, they have to wade out into the unfamiliar territory of the surf.

Yes, there is some necessity of having sterile and unnatural exam rooms that are centralized for efficiency and throughput.

But l feel like we doctors are getting sucked out to sea. As care provider organizations like hospital and primary care practices consolidate, we are pulled back from the shore. We are pulled out of communities, away from neighborhoods, and are comfortably situated within the colossus of gleaming buildings and parking garages.

I admitted an 84 year old woman to the hospital recently with hip pain that had been ongoing for over a year. She had just been admitted two weeks ago with constipation and hip pain and asked to see her primary care doctor. I asked her why she wasn't able to see her doctor, and she told me it was too hard--too much time on the phone, traffic, parking, schedule availability. Instead, she got a mammogram.

Like so many, this woman feels stranded on the dry sand.

I want to get out of the water and up there on the sand too. I aspire to provide the basics of care-- hip pain and hypertension-- but also grapple with issues that threaten health that are completely unreachable from the water. I want to help with racism, gun violence, poverty, housing, education, and everything else.

The "system" is not going to change course and put us up on the sand. We doctors have to figure out how to get up there.

Oddly, it's there every time I step outside. I walk through the sand, past the housing developments and impoverished minority groups, through the structural racism and violence, and out into the waters of the medical industrial complex. I comfortably turn a blind eye, ease into the surf, and wait for problems to come to me.