Rethinking a No-Brainer

What does someone having a heart attack look like? I think the New York Times captured what many of us probably have in mind, when they published this picture as part of a recent series on advances in cardiovascular care:

Nash_Blog_ImageMark Makela for The New York Times. Retrieved from http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html

Here is the iconic middle-aged guy, in extremis, pointing to his chest, with a team of health care professionals at the bedside. There are also signs of initial management – he has ECG electrodes on his chest, an IV in his left arm, what looks like monitor/defibrillator pads on his right chest and below his left arm and, of course, an oxygen mask.

What is wrong with this picture?
Continue reading Rethinking a No-Brainer

The New Paradigm

A recent FDA advisory panel recommended the approval of 2 new agents in a novel class of cholesterol lowering drugs known as PCSK-9 inhibitors. What makes this remarkable is that these drugs illustrate all the promise and pitfalls of modern pharmaceutical development.

First, a little science. The target of the new drugs – a protein named proprotein convertase subtilisin/kexin type 9 (PCSK-9) – was discovered in 2001. Two years later, investigators reported that “gain-of-function” mutations in the gene that codes for PCSK-9 were associated with familial hypercholesterolemia and high rates of atherosclerotic vascular disease. Mutations of the gene that led to reductions in the function of PCSK-9 were associated with low LDL-cholesterol levels, and a lower incidence of vascular disease. That made the compelling case that PCSK-9 had a counter-regulatory function in LDL-cholesterol metabolism, so that interfering with its function would lead to lower cholesterol levels.

Continue reading The New Paradigm

Crowdsourcing CPR

I have written previously about the potential impact of mobile apps and ubiquitous computing on health and healthcare delivery, but I admit I did not see this one coming. The current issue of The New England Journal of Medicine has a report from a research group in Sweden that developed a system – and tested it in a randomized controlled trial – to use smartphones to alert CPR-trained bystanders when there was a nearby cardiac arrest. This figure from the paper describes how it works:

Image1

Continue reading Crowdsourcing CPR

Yelp!

I have written previously about some “aha moments” that I have had as a clinician, when something that I knew was coming seemed to arrive with a thud in my own practice. I had another one of those moments a couple of weeks ago.

I was finishing up with a new patient, and had explained to him and his wife my assessment and recommendations, and had answered a bunch of questions they had.  I was frankly feeling pretty good about how the encounter had gone and as he was walking out of the exam room he said (more or less): “thanks doc; I’m glad I came to see you, and I am going to give you a really nice review on Yelp.” He was not kidding.

I didn’t know quite what to say immediately, but I ended up thanking him (somewhat awkwardly, I suspect) and then recovered enough to tell him that while I would – of course – appreciate a nice review on Yelp, I wanted him to know that he might be getting a patient satisfaction survey in the mail, and I would really appreciate it if he filled it out and sent it back in. Encounter over. New world order in place.

Continue reading Yelp!

Memorial Day

Last year I pointed out that Memorial Day was slipping in our collective consciousness from a day of solemn remembrance of those who died in the service of our country to just another “vacation Monday” or the marker of the start of the Summer season.

A recent experience reinforced for me just how important it is for us to make sure we never lose the deeper meaning of the day.

My wife and I traveled to Washington, DC a couple of weeks ago to witness the “arsenal of democracy” flyover. The event included over 50 WWII warplanes, and coincided with the 70th anniversary of “V-E (Victory in Europe) Day” – the defeat of Germany by Allied Forces. As an airplane buff, I found the flyover stirring. It was an historic opportunity to see the “warbirds” aloft, flying in formation, instead of on the pages of history books or on static display in a museum.

Continue reading Memorial Day

Professionalism

Every so often the Journal of the American Medical Association (JAMA) is devoted to a single topic. The May 12 edition was devoted to “professionalism and governance” and the articles addressed a range of related subjects from medical education to board certification. I was particularly drawn, for obvious reasons, to the section on “professionalism and employment.”

I think it is fair to say that physicians have often cited their commitment to professionalism as a justification for the high value placed on independent private practice. That is, independence – of insurance companies, corporate overlords or pretty much anybody telling them how to practice – is the only way to assure that they can consistently act in the best interests of their patients.

This way of thinking is now severely challenged.

Continue reading Professionalism

Congress and Dr. Bayes

I was driving to work the other day, and there was a story on the radio about the Congressional reaction to the latest recommendations for breast cancer screening from the United States Preventive Services Task Force (USPSTF).

Here’s the background. USPSTF published recommendations in late 2009 for the use of screening mammography in different age groups. For women between 40 and 50 years old, the panel concluded “that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.” In other words, they did not recommend biennial mammograms – which they did for women between 50 and 74 years old – for the younger cohort. That led to a firestorm of criticism that younger women would be “denied” mammography, and Congress wrote into the Affordable Care Act that “exchange” (Obamacare) insurance plans cover regular mammography for women over 40.

Fast forward to now.

Continue reading Congress and Dr. Bayes

I Guess They Were Listening

Some time ago, I wrote that the maintenance of certification requirements of the American Board of Internal Medicine (ABIM) were more like a shakedown than a civic-minded attempt to improve the quality of medical care. I was not alone. Many professional societies, including, I am happy to say, the American College of Cardiology were highly critical of the program.

The good news is that the ABIM heard the critics loud and clear. Despite earlier public defense of the policies, it has since done a complete “about face” and is now in a “listening” mode in anticipation of revising the program.

Continue reading I Guess They Were Listening

Mistakes about “Patient Satisfaction”

I had two experiences recently that reminded me that many doctors and nurses remain resistant to measuring and improving how patients experience the care we provide. One was a face-to-face discussion with a senior physician. The other was reading an article by a nurse. Both the doctor and the nurse denounced the growing focus on the patient experience by citing the threat to quality of care, and I believe both of them were totally wrong.

The encounter with the physician came as I addressed a group of newly hired physicians. As I typically do in these circumstances, I outlined our Medical Group’s commitment to increasing the visibility of the results of our patient experience surveys. We have been providing our physicians with reports on their patients’ feedback for the better part of a year, and we anticipate posting physician-specific results on our public website within a few months. During the Q&A, one of the physicians objected to the plan, saying that “patients can’t judge the quality of care that we provide.”

Continue reading Mistakes about “Patient Satisfaction”

Patient Advocates? Really?

I was disturbed by a recent article in the New York Times about the Texas Medical Board. The piece described the decision by the Board to sharply curtail the use of telemedicine in the state. Specifically, the Board mandated that telemedicine services could only be provided in the context of a pre-existing patient/physician relationship, and that such a relationship must be established face-to-face, and not via electronic means. According to the Times, the restrictions were strongly supported by the Texas Medical Association.

Sigh.

This seems to me to be a wrongheaded, backward looking and overall pretty lame attempt to stem the inexorable tide of patients and physicians connecting in new ways. I really wish I could believe the Board member who said he voted for the new restriction because he was “terribly, terribly worried about the absence of responsibility and accountability” in electronic encounters. It sounded to me, instead, that he was “terribly, terribly worried” about a new business model for medical care that provides greater convenience and lower cost to patients than traditional office visits.

Continue reading Patient Advocates? Really?