Thoughts, on Getting My Photo Taken at a Medical Appointment

A funny thing happened at my doctor’s appointment on Friday. I checked in, and after confirming that my address and insurance hadn’t changed since last year, waited for approximately 10 minutes. A worker of some sort, likely a med-tech, called me to “take my vitals.”

She took my blood pressure with a cuff that made my germ-phobic self run for self-regulation, i.e. I stayed quiet and didn’t express my concern about the fact that it looked like it hadn’t been washed in years. I value this doctor among others in my care, and I didn’t want to complain about anything. Then the woman took my weight. And then she asked if she could take my picture, “for the hospital record.”

I couldn’t contain my wondering self. “What is the purpose of the picture?” I asked.

“It’s for the record,” she explained. “For security.”

I thought about it. My picture is pretty much public domain at this point in my life, a decision I made upon deciding not to blog anonymously. Besides, most everyone at the medical center used to know me, including the receptionists, janitors, cafeteria cashiers, nurses’ aides, social workers, deans, full professors, geneticists, fellows in surgery and old-time voluntary physicians, among others who work there. So why didn’t I want this unidentified woman who works in my oncologist’s office to take my picture?

It made me uncomfortable, and here’s the reason: My picture is a reminder that, without it, I might be like any other patient in the system. They (administrators?, nurses, other docs, maybe even my future doctors) will need or want the picture to recall and be certain who Elaine Schattner is.

Don’t get me wrong. I agreed to the photo after all of maybe 20 seconds deliberating. (And my doctor was, I soon learned, duly informed I’d “had an issue” with it. Was that for just asking the reason?) The unidentified med-tech person used an oddly small, ordinary pink camera to complete her task.

When I met with my doctor, she explained that the photo is for security and, essentially, to reduce the likelihood of errors. The hospital has records of so many thousands of patients, many who have similar or identical names. There are good reasons to make sure that your notes on “Sally Smith” are entered into the chart of “Sally Smith” who is your patient.

It’s understandable. I remember when at the nurses’ station there’d be a sign (on “our” side) saying something like “CAREFUL: Anna Gonzalez in 202, Alma Gonzalez in 204b,” or something like that.

Patients blur.

It’s hard, veritably impossible, for most doctors and nurses to keep mental track of all of the patients they’ve ever seen and examined. There’s utility in the new system. Yes, it’s a good idea for a doctor, say upon receiving a call from a woman she hasn’t seen in 3 or 6 or 9 years, to see her picture in the chart, as a reminder.

But I hope my doctors know who I am, and not just what I look like in the image.

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A Medical School Problem Based Learning (PBL) Parody of ‘The Office’

Last week a video came my way via ZDoggMD, a popular blog by doctors who are not me.

The Office Med School Edition

The clip is a parody of The Office about Problem Based Learning (PBL).

In a typical PBL, the students meet regularly in small groups. On Monday they begin with clinical aspects of a case. The process involves finding information and researching relevant topics to “solve” the diagnosis and /or a treatment dilemma. Over the course of each week the students move forward, working through a hypothetical patient’s history, physical exam and lab studies to the nitty-gritty of molecules, genes and cells implicated in a disease process.

It’s a lot of fun, usually.

The video was uploaded in February, 2007. It’s attributed to a group of med students at the University of Pittsburgh, class of 2009.

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The Immeasurable Value of Continuity of Care

Today I visited my internist for a checkup and flu shot. We talked about how I’m doing, and she examined me, and we discussed what procedures I ought have done and not done. She’s been my doctor since the summer of 1987, when I was an intern at the hospital.

We reviewed so much that has happened in the interim.

How rare it is, now, to have a doctor who knows me. Continuity in care is so valuable.

One of my greatest fears is being in the hospital again, and having hospitalists – doctors who work full-time in the hospital – be the ones to see me each day, and make decisions about what I need. Yet I’m bracing for it because, well, that’s how it is, now.

From a health care administration perspective, I recognize the value of delegating inpatient care to physicians who are not my usual doctors. And from the perspective of a physician who after hours and on weekends, would walk to and from the hospital, back and forth, countless times, to see my patients when they were sick, I know it’s neither cost-effective nor wise for physicians to push themselves to get over to the hospital before or after they’ve gone home, and called everyone back, and maybe eaten dinner. Doctors need rest, too.

But as a patient, when I’ve been in the hospital, nothing was more reassuring than visits by my usual doctors – my internist, my oncologist, my surgeon, my orthopedist…Being cared for by strangers, however competent, is not the same, although there may never be a study to prove it.

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On Admitting Nice, Ethically-Minded People to Med School

This week the Times ran a leading story on a new med school admission process, with multiple, mini-interviews, like speed dating. The idea is to assess applicants’ social, communication and ethical thinking (?) skills:

…It is called the multiple mini interview, or M.M.I., and its use is spreading. At least eight medical schools in the United States — including those at Stanford, the University of California, Los Angeles, and the University of Cincinnati — and 13 in Canada are using it.

At Virginia Tech Carilion, 26 candidates showed up on a Saturday in March and stood with their backs to the doors of 26 small rooms. When a bell sounded, the applicants spun around and read a sheet of paper taped to the door that described an ethical conundrum. Two minutes later, the bell sounded again and the applicants charged into the small rooms and found an interviewer waiting. A chorus of cheerful greetings rang out, and the doors shut. The candidates had eight minutes to discuss that room’s situation. Then they moved to the next room, the next surprise conundrum…

This sounds great, at first glance. We all want friendly doctors who get along. It might even be fun, kind of like a game. (Sorry for the cynicism, injected in here, but it’s needed.) I’d even bet that the interviewers and successful interviewees would emerge feeling good about the process and themselves.

But don’t you think most premed students, who get through college, and numerous letters of recommendation, take the MCATS and achieve scores high enough to get an interview, are smart enough to get through this social test without failing? It’s what these young men and women are thinking, internally, that matters. According to the same article, the country’s 134 medical schools have long relied almost entirely on grades and the MCAT to sort through over 42,000 applicants for nearly 19,000 slots.

My math: that means nearly 19 out of 42 (almost half!) of med school applicants get in, here in the U.S.

If we want future doctors who are smart enough to guide patients through tough, data-loaded, evidence-based and ethically-complex decisions, we should make the academic requirements for entry more rigorous, especially in the areas of science, math and analytical thinking.

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Running 2 Lists That Might Lessen the Costs of Oncology Care

Recently the NEJM ran a Sounding Board piece on Bending the Cost Curve in Cancer Care. The authors take on this problem:

Annual direct costs for cancer care are projected to rise — from $104 billion in 20061 to over $173 billion in 2020 and beyond.2…Medical oncologists directly or indirectly control or influence the majority of cancer care costs, including the use and choice of drugs, the types of supportive care, the frequency of imaging, and the number and extent of hospitalizations…

The article responds, in part, to Dr. Howard Brody’s 2010 proposal that each medical specialty society find five ways to reduce waste in health care. The authors, from the Divisions of Hematology-Oncology and Palliative Care at Virginia Commonwealth University in Richmond VA, offer two lists:

Suggested Changes in Oncologists’ Behavior (from the paper, verbatim – Table 1):

1. Target surveillance testing or imaging to situations in which a benefit has been shown.

2. Limit second-line and third-line treatment for metastatic cancer to sequential monotherapies for most solid tumors.

3. Limit chemotherapy to patients with good performance status, with an exception for highly responsive disease.

4. Replace the routine use of white-cell-stimulating factors with a reduction in the chemotherapy dose in metastatic solid cancer.

5. For patients who are not responding to three consecutive regimens, limit further chemotherapy to clinical trials.

Suggested Changes in Attitudes and Practice (same, Table 2):

1. Oncologists need to recognize that the costs of cancer care are driven by what we do and what we do not do.

2. Both doctors and patients need to have more realistic expectations.

3. Realign compensation to value cognitive services, rather than chemotherapy, more highly.

4. Better integrate palliative care into usual oncology care (concurrent care).

5. The need for cost-effectiveness analysis and for some limits on care must be accepted.

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For today, I’ll leave this provocative list without comment except to say that it should engender some long and meaningful, even helpful discussion.

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Quotes on Oncology, Via Forbes, and a Spiraling Helix

Forbes kept a close eye on the annual ASCO meeting in Chicago. On THE MEDICINE SHOW, Forbes’ Matthew Herper provides a précis of a speech by outgoing ASCO President Dr. George Sledge.

Here are my two favorite parts:

“So what happens when, a few years from now, a patient walks into a doctor’s office and hands a physician a memory stick loaded with gigabytes of personal genomic data?” Sledge asks. His answer: the flood of data will help doctors and patients, but things will get “very, very complicated.”

and

…Doctors will need real-time access to clinical data from all practice settings. This in turn will require interoperable databases using common terminology. Health information technology should offer on-the-spot decision support to oncologists and patients facing the increasingly complex tapestry revealed by modern genomics. It should provide individualized, ready access to a clinical trials systems. It should support appropriate coverage and reimbursement for services. And it should aggregate data so that we can learn from every patient’s experience.

DNA orbit animated smallWhat he’s saying, in a nutshell, is that oncologists will need to know science and have access to effective HIT to interpret and act upon the ever-growing pile of info on cancer genetics as it applies to people in general and individual patients. I recommend the full read.

An added perk in the MEDICINE SHOW piece is a terrific, gyrating DNA model courtesy of Wikipedia (@Forbes!).

For an additional twist (PM, 6/7), turns out Wikipedia offers a mutable Medicine Show of its own.

What goes around…?

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TV Meets Real Life Oncology, and Anticipating the MCATs

Yesterday I wrote on some tough decisions facing a TV show‘s protagonist. She’s got metastatic melanoma and might participate in a clinical trial when the show resumes.

Now imagine you’re an oncologist, or a real patient with this killing disease – you really need to be on top of new developments, to understand the pros and cons, because someone’s life depends on it.

If you’re the doctor in the relationship, you need keep abreast of current information for all the other tumors types of patients in your care: what are the new findings, if any, what are the limitations of the data. You need to know how the advances apply to an individual person who, most likely, has another condition or two, like high blood pressure or, say, osteoporosis.

Oncologists ought to be familiar with new drugs, and how those compare to old ones, and the side effects, and the distinctions between tumors with and without BRAF mutations. They should know what BRAF stands for.

Melanoma is one form of skin cancer. We understand now there are breast cancer subtypes – with distinct behavior and responsiveness to treatments, with and without inherited and acquired genetic mutations (BRCA-1 and -2 were identified well over 10 years ago; there’s much more known now), dozens of lymphoma forms and innumerable leukemia subtypes. Lung cancer, prostate cancer, brain cancer… Each is a group of diseases.

But the science physicians apply in their work doesn’t just apply in oncology. Even in traditionally “softer” fields of medicine, like pediatrics, doctors need to know how congenital diseases are diagnosed with newer, cheaper methods for testing mutations; in gynecology, doctors need to know about inherited clotting dispositions; in psychiatry, doctors give medicines with complex metabolic effects that involve, or should involve, some grounding in modern neuroscience.

This is why we need to keep the MCAT hard. (I’ll write more on this current issue in medical education, soon.)

Have a great weekend!

ES

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The Medical Word of the Week is Theranostic

The author learned a new word this weekend while attending the annual meeting of the Association of Health Care Journalists in Philadelphia.

In a richly-informative session on ethics of clinical trials, one of the speakers, Dr. Jason Karlawish – a bioethicist, geriatrician and Alzheimer’s researcher at the University of Pennsylvania, taught me a new term: theranostic (alt. spelling: theragnostic).

The neologism calculatingly brings together the concepts of medical therapy and diagnosis. This goes beyond biomarkers, he explained; theranostics are novel tests or diagnostic markers that would identify patients who, as defined, benefit from a particular therapy.

The first international conference on theranostics will be held in June, he told the audience.

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Internet-Based Medical Information May Prove More Trustworthy Than Printed Texts

Today Ed Silverman of Pharmalot considers the case of a ghost-written medical text’s mysterious disappearance. The 1999 book, “Recognition and Treatment of Psychiatric Disorders: A Psychopharmacology Handbook for Primary Care,” (reviewed in a psychiatry journal here) came under scrutiny last fall when it became evident that the physician “authors” didn’t just receive money from a relevant drug maker, SmithKline Beecham; they received an outline and text for the book from pharmaceutical company-hired writers.

poster for the X-Files

The book is no longer evident at the website for STI (Scientific Therapeutic Information), the company that provided authorship “help.” I tried to get a copy on Amazon.com, where it’s said to be temporarily out-of-stock. The work remains listed in the Library of Congress on-line catalog: #99015420.

I’m reminded of clinical handbooks I used all the time when I was practicing hematology and oncology. At the hospital, I’d get freebie, small-sized chemo regimen primers that conveniently fit into my white coat pocket. In retrospect, perhaps I didn’t adequately check the authors’ credentials on those mini-book sources. It was too easy to take that information and keep it at hand, literally, especially in the times before we had constant Web access.

And I’m struck by how the Internet – that infinite bucket of once-lowly or at-best mixed-quality information doctors disparaged for years – may prove a better information source than printed books.

It’s a minor paradox, or a twist in trust –

Now, with a few clicks if you know where to look, you can get recommendations for chemo dosing from reliable sources, like the NIH or peer-reviewed journal articles. Although transparency about physicians’ ties to industry is not nearly yet where it should be, you can find out about more about an author’s connections and potential conflicts of interest than at any time in medical publishing history.

What we write here can’t be discarded, burned, or go out of print.

(And it may be corrected, readily, before the next edition.)

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In Defense of Primary Care, and of Sub-Sub-Sub-Specialists

An article in the March 24 NEJM called Specialization, Subspecialization, and Subsubspecialization in Internal Medicine might have some heads shaking: Isn’t there a shortage of primary care physicians? The sounding-board piece considers the recent decision of the American Board of Internal Medicine to issue certificates in two new fields: (1) hospice and palliative care and (2) advanced heart failure and plans in-the-works for official credentialing in other, relatively narrow fields like addiction and obesity.

The essay caught my attention because I do think it’s true that we need more well-trained specialists, as much as we need capable general physicians. Ultimately both are essential for delivery of high-quality care, and both are essential for reducing health care errors and costs.

Primary care physicians are invaluable. It’s these doctors who most-often establish rapport with patients over long periods of time, who earn their trust and, in case they should become very ill, hold their confidence on important decisions – like when and where to see a specialist and whether or not to seek more, or less, aggressive care. A well-educated, thoughtful family doctor or internist typically handles most common conditions: prophylactic care including vaccinations, weight management, high blood pressure, diabetes, straightforward infections – like bacterial pneumonia or UTIs, gout and other routine sorts of problems.

On the other hand, specialists can be lifesaving when highly-detailed expertise matters. There are limits to how much a general internist knows about chemotherapy, for example. Even within the field of medical oncology, a subspecialty of internal medicine, there are doctors who only see patients with particular kinds of cancers. When I had breast cancer, for example, I chose an oncologist whose practice consists almost entirely of patients with breast cancer and related diseases. If someone in my family has a lymphoma, I’d advise them to consult with someone who, for the most part, patients with lymphoma and similar disorders. Why? Because each of these cancers represent a complex group of malignancies, and successful therapy depends in part on the doctor’s familiarity with each of the specific subtypes and the relevant, current data for those. Treatment of lung cancer involves choosing among a different set of drugs than would be considered for brain or kidney cancer.

I mention oncology, here, because I’m most familiar with this field. But the same holds, for example, in the subspecialty of Infectious Diseases: knowing about all the new HIV drugs, in pregnant women, children and adults, involves a different set of knowledge than knowing about parasites in the tropics, and that differs from knowing about viral and other, unusual infections in patients are immunocompromised after kidney, heart or lung transplants.

In each of these settings, expertise can reduce errors – because specialists are more likely, in the first place, to establish a correct diagnosis and, next, to prescribe the right therapy based on the best evidence available.

The same holds for other medical specialties, apart from Internal Medicine. As I’ve described before, the radiologist who interpreted my routine mammogram and follow-up sono was a breast imaging specialist. The orthopedist who reconstructed my spine is a scoliosis spine surgeon. I am confident that I wouldn’t be here and feeling as well as I do if it weren’t for their expertise.

You could argue that it’s impossible to provide these kinds of sub-sub-specialists to people in rural areas, or that it’s too expensive, but I don’t think either of these factors should be limiting. To a large extent, experts might work with primary care providers and communicate with patients via Telemedicine and Skype-like technologies. As for surgical subspecialties, it may be that patients would find it worthwhile to travel to a regional center where a specialized procedure is done routinely, as opposed to having an operation in a local hospital where the doctors perform a certain kind of surgery – say a laparoscopic splenectomy, for example – only a few times each year.

There’s a tradeoff, as discussed in the NEJM piece, between increasing use of specialists and fragmentation of care. I think this concern is legitimate, based on my experiences practicing medicine and as a patient. But I do think we need specialists, and sub-specialists if we want doctors who can answer their patients’ questions, i.e. who really know what they’re doing.

I was a bit surprised that the article mentions a survey of physicians in which the majority of respondents reported that “professional image” was the primary reason for seeking subspecialty credentials. While this may be true, I don’t think doctors’ motivation matters in this. From the public’s perspective, what’s important is that hand surgeons know how to do hand surgery, and that a heart specialist knows how to interpret an echocardiogram, and that the hospitals where they work not let them practice if they’re not appropriately credentialed.

In cutting health care costs, or in trying to so, I don’t think it makes sense to reduce the number of physicians or to short-cut their educations by way of 3-year medical schools. Rather we need well-trained primary care doctors we can rely on, who know the limits of their knowledge as much as they understand medicine, and top-notch specialists, both.

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Crowd-Sourcing a Medical Puzzle

The Times ran an intriguing experiment on its Well blog yesterday: a medical problem-solving contest. The challenge, based on the story of a real girl who lives near Philadelphia, drew 1379 posted comments and closed this morning with publication of the answer.

Dr. Lisa Sanders, who moderated the piece, says today that the first submitted correct response came from a California physician; the second came from a Minnesota woman who is not a physician. Evidently she recognized the condition’s manifestations from her experience working with people who have it.

The public contest – and even the concept of using the word “contest” – to solve a real person’s medical condition interests me a lot. This kind of puzzle is, as far as I know, unprecedented apart from the somewhat removed domains of doctors’ journals and on-line platforms intended for physicians, medical school problem-based learning cases, clinical pathological conferences (CPC’s) and fictional TV shows.

In this example, the patient’s diagnosis was known, and treatment successfully implemented, before publication. Surely the Times legal team carefully reviewed those scanned commercial lab reports with the wiped-out patient’s name and address, and likely they got the OK from the patient and her family to run the story as they did. There were sufficient details included that she’s likely identifiable to some people in her community.

The case is instructive at many levels: It’s not just about the girl and her symptoms and her disease, and how doctors think, but about how the population of New York Times readers approached it over the course of 24 hours. A question an editor, if happy with the “results” – i.e. the on-line turnout (clicks, emails, tweets…) and lack of flak – might ask is what sort of case to use next week or next month, and how perhaps to improve on the presentation.

The question I ask as a physician is this: why we don’t have this sort of crowd sourcing for tough, unsolved medical cases? Privacy is an obvious concern as is, perhaps, physicians’ fear of missing something or being wrong. Also, if a diagnosis isn’t already determined, the responsible doctor might end up (and likely would) order more tests and, perhaps, harm the patient by chasing zebras and heeding some well-intentioned but absurd or simply wrong suggestions from a diverse collection of world-wide readers. So there would be a problem of “too many cooks” among other issues.

On the other hand, a single physician dealing with a challenging case would have, potentially, access to the expertise of millions of people, perhaps a few who have genuine insight and have seen a rare situation before. Doctors needn’t think in silos.

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A Video About a Robot and a Patient

Since Watson won on Jeopardy, there’s been lots of talk of robots assuming doctors’ roles. Ten years into our future, machines with programmed empathy and nuanced diagnostic skills will solve diagnostic dilemmas, deduce optimal treatment and make us well.

Yesterday I found a new Xtranormal video, this one crafted by Dr. Charles of his excellent Examining Room blog, on Dr. Watson and the 7 Qualities of an Ideal Physician.

from the Examining Room of Dr. Charles

Dr. Charles cites a 2006 Mayo Clinic Proceedings review on what patients say are essential characteristics of a good physician: The ideal doctor is confident, empathetic, humane, personal, forthright, respectful, and thorough. In this clever, short movie crafted by Dr. Charles, the robot-doctor tries to demonstrate his capability in each of these dimensions in his interaction with a cartoon patient.

I hope the folks over at IBM, who are collaborating with real medical centers now about designing artificial doctors’ intelligence, might take a close look at this video.

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Sad Stats for Science Knowledge in U.S. Schools

Today’s Times reports on our nation’s students’ poor science test results. The results are bleak: only 34% of fourth graders scored at a “proficient” level or higher; just 30% of eight graders scored at a proficient level or higher; 21% of twelfth graders scored at a proficient or higher level in science.

The mega-analysis, prepared by the National Center for Education Statistics, derives from 2009 testing of 156,500 fourth-graders and 151,100 eighth-graders, with state-by-state and nationwide metrics of those, and of 11,100 twelfth-graders. Student scores were ranked at one of three science knowledge levels for each peer group: advanced, proficient and basic, as defined by the Department of Education. Only a tiny fraction – as few as 1 or 2% of students – attained “advanced” scores on the science exams.

The complete report card analyzes the data by race, sex, urban vs. rural districts, private vs. public schools and other factors, and includes interactive state maps.

These numbers don’t bode well for our future-docs, or for empowered patients. With 70-80% of high school seniors lacking proficiency in science, informed consent and meaningful participation in health decisions are just theoretical concepts for most U.S. citizens.

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First Inspection of Google’s Anatomy


Google Woman (Body Browser, clad)

This morning I toured Google’s new Body Browser. The trip wasn’t as easy as I’d envisioned; I got sidetracked on my way, having to update my Web browser before entering. The site requires an advanced Web browser, like Chrome beta or Firefox 4.0, to accommodate 3-D graphics.

Update accomplished, I forged into Google-woman’s frame. (There is no man available, as yet.)

muscles, frontal view

The muscles appear well-defined, though I’m no orthopedist. The platform reveals the piriformis, an obscure muscle beneath the glutes for which a physical therapist once gave me strengthening exercises. I could see the psoas major, which I’d learned years ago to check for tenderness by examining the abdomen while moving a patient’s hip in a specific manner.

The bones could definitely use some work. The 5 lumbar vertebrae should be numbered, as might be the 12 thoracic and 7 cervical elements of the spine, to name a few among many missing details in the skeleton. At various points the woman’s blood vessel system, or circulation, mixes in with her peripheral nerves. The brain findings are surprisingly limited. (all accessed 12/29/10)

This version of Google’s Body Browser remains in lab mode, for good reason. Still, it’s pretty amazing – you can twist and turn the human’s body, peel away layers and isolate nerves of interest. Knowing some anatomy and terms, I honed right in on the woman’s trigeminal nerve, choosing an oblique and semi-transparent view of her neck and head.

piriformis muscle, found

I think the potential for this Web-tool is huge. Doctors could learn with it. And although some of my colleagues might mind my saying so, this sort of platform might eliminate or at least reduce the need for so many cadavers for medical school education. As for providing patients with understandable information, this has tremendous value. Imagine sitting in a physician’s office with a computer screen as she points to a joint that needs repair, in real-time and 3-D, or explains the risks of prostate surgery, due to the nerves and other structures that run through or nearby that particular gland.

trigeminal nerve, revealed

Google’s developers have a lot of work ahead on this project. Like Google Maps, this should allow people to see things that will help them make sound decisions. We’re not quite there yet, but close.

For now it’s fun to look click through Google’s anatomy. It’ll be interesting to see how this terrific application progresses.

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Stem Cells, Breast Reconstruction and a Magazine Cover

The cover of the November print edition of Wired features large, unnatural-appearing cleavage. Inside and toward the back of the issue, a curious article ties together stem cells and the future of breast reconstruction. It got my attention.

Wired, November 2010 issue

The detailed and admittedly interesting piece, by Sharon Begley, describes what’s science or science fiction: first humans, such as some plastic surgeons, remove adipose tissue, a.k.a. fat, by a well-established cosmetic surgery procedure called liposuction, from a body part where there’s a fat surplus – such as the belly or backside; next, laboratory workers purify and grow what are said to be stem cells from that that fat; finally, they use a nifty, calibrated and expensive device to inject those fatty stem cells where women want, such as in a hole or dimpled breast where a tumor’s been removed.

The story starts, unfortunately and distractingly, with a portrait of a male, enterprising and PowerPoint presentation-giving CEO of a biotech company, Cytori Therapeutics. Toward the end of the article, the author provides stats to support the potential business. Ultimately, improved breast cancer survival means that greater numbers of women will live more years after a lumpectomy or mastectomy, she explains. The reconstruction market may expand further, still, because some women opt for prophylactic mastectomies upon positive genetic testing for a BRCA mutation. Others, without cancer or high risk, might simply want to use these adipose-derived stem cells for cosmetic breast augmentation. What’s clear, if nothing else, is that women’s breasts are perceived as a commodity.

In between the money elements of the discussion, there’s some cool science about adipose-derived stem cells, which according to the cited scientists are quite prevalent in fatty tissue and relatively easy to grow if you give them some blood to feed on in the lab. A putative advantage of the cells is that they draw blood vessels to the area of engraftment, which is a concern to this oncologist (me) and, evidently, to an FDA panel that has not yet approved of this innovative method of breast reconstruction in women who’ve had breast tumors.

I’m not convinced, at least from what’s reported in this Wired article, that the cells used in this process are true stem cells, based on the high numbers the scientists describe finding so readily, and in rich proportions, in human fat tissues. It could be, for example, that what they’re isolating are really primitive adipose cells that can, indeed blend into the breast tissue and even recruit blood vessels as described, but aren’t true, pluripotent stem cells – the kind that can form any kind of blood cell or heart cell or neuron. Perhaps stem cells just sound sexy, at least to investors.

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Five Ways to Improve the Quality and Success of Breast Cancer Screening by Mammography

Here are some ideas on how we might reduce the incidence of metastatic breast cancer, by making high-quality mammography available to all women:

1. Modernize all breast imaging facilities. All should comply with the Mammography Quality Standards Act and Program (MQSAP) of 1992.

2. Ensure that radiologists, technicians and other BC screening workers are up to date: requirements for continuing medical education in an academic, unbiased (non-pharma or biotech setting), should be strict. We depend on practitioners’ current knowledge of breast imaging methods, breast biopsy techniques, hygiene, information technology (IT) and patient privacy laws.

3. Implement digital mammography in all screening facilities; Digital images allow radiologists to adjust the contrast, magnify or otherwise highlight areas of concern, to better analyze potential lesions without subjecting patients to extra x-rays.

4. Supplement mammograms with sonograms of the breasts. These inexpensive tests can help radiologists discern cysts and other benign lesions from malignant tumors. In some situations, a radiologist inspecting a sonogram can spot a small solid abnormality that’s missed in a mammogram. In principle, this low-rad combo – of digital mammography and breast sonography – would increase sensitivity and specificity of breast cancer screening.

(5.) Consider transmitting digital images to breast screening centers, so that expert radiologists can review every woman’s films.

As Sue, a woman who’s had breast cancer told me last month: “You don’t want a radiologist who’s just looked at someone’s broken foot examining your mammogram.” She’s right: Expertise can make a huge difference in clinical outcomes.

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News, and Thoughts, on Comparative Effectiveness Research

Last week the U.S. Government Accountability Office (GAO) appointed several new members to the board of the Patient-Centered Outcomes Research Institute (PCORI). This group will oversee the application of comparative effectiveness research in health care reform. The panel’s composition was the subject of two posts today by Merrill Goozner, a long-standing observer of health care economics and journalist.

The group may play a key role in forming health care policy in the years ahead. According to the Patient Protection and Affordable Care Act, signed into law in March of this year, the PCORI is slated as a private, non-profit agency. The Institute’s purpose is:

to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis that considers variations in patient subpopulations, and the dissemination of research findings with respect to the relative health outcomes, clinical effectiveness, and appropriateness of the medical treatments, services, …”

This is no small task, to say the least.

What is comparative effectiveness research and why does it matter? The idea, basically, is to inform medical decisions with relevant data derived from well-designed clinical trials. This sort of research will provide the foundation for evidence-based medicine (EBM).

Some casual readers of this blog may not appreciate the extent to which I support these endeavors. I do, 100 percent. I say this for several reasons:

First, as a patient: We need to obtain as much information as possible on the best way to treat common and rare medical conditions that arise in humans. Knowing which treatments work, and don’t, ultimately will promote care that’s effective and diminish use of procedures, devices and medications that are ineffective and/or harmful.

Second, as a citizen: We don’t have a surplus of health-care resources to throw around, so to speak, in vain efforts to treat things that can’t be fixed.

As an oncologist, I was not one to give treatments that I didn’t believe would help a patient to feel better and, ideally, get well. Rather, I think the value of chemotherapy and other treatments needs be demonstrated in clinical trials prior to their routine administration, or that their worth be measured otherwise – such as by careful testing of how a drug might work in a subset of patients or even in a particular patient who has a condition like breast cancer and, upon careful monitoring, it is apparent that nothing helps except Avastin in her case.

Third, as a doctor: I would never want to cause avoidable harm to a patient. If a drug, device or procedure is ineffective or damaging, we shouldn’t often prescribe that, if ever. The best way to help patients get well, and harm them less, is by knowing what works and what doesn’t in most cases and by knowing the limitations of aggregated, statistically-valid data applied to individual patients.

Cost analyses are needed, too, but that’s a somewhat separate issue.

I wish the panel good luck in their important work ahead.

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No More Clipboards

“This kind of aid to decisions, spread across tens of thousands of decisions every day, leads to much, much lower costs with no intrusion on clinical autonomy”

– David Blumenthal, M.D., M.P.P., National Coordinator for Health Information Technology, U.S. Department of Health & Human Services, speaking at Weill-Cornell Medical College, Sept. 15, 2010

Last week I had the opportunity to hear Dr. David Blumenthal, head honcho for national health IT development, give a presentation on electronic health records (EHR), the future of health information technology (IT) and meaningful use. He spoke at a health policy colloquium at Weill-Cornell Medical College.

The points he made were clear – to begin, that health IT encompasses three areas of value:

1. Electronic Health Records (EHR)

2. Health Information Exchange (HIE)

3. Clinical Decision support (CDS)

Notes on Electronic Health Records:

“What do patients think if you ask them what’s the value of an EHR?” he half-asked the audience, a group of 250 or so, mainly physicians. He answered: “No more clipboards.”

The problem is that doctors are reluctant to take on electronic systems. Prior to the Health Information Technology for Economic and Clinical Health Act (or HITECH Act) of 2009, only 6 percent of physicians used fully-functional EHRs; only 20 percent used any EHR in their practices. Hospitals weren’t doing any better, he said. We’re running far behind our European counterparts in this arena.

“What’s the barrier?” he asked, and answered: “Money is numbers one through eight. Then logistics, technical problems and fear.”

Physicians, and hospitals, are concerned about buying into systems that will become obsolete. “And it’s a psychological issue,” he added. “That comes in whenever you’re asking people to change.”

The benefit of EHRs will be more efficient care and better health outcomes. As things stand, the quality of a nurse or doctor’s care is limited by the information they have about the patient in front of them. If providers have access to a patient’s compete record – say a cardiologist who’s evaluating a patient with notes provided by the primary care provider (PCP) – that’ll save both parties (patient and doctor) time, reduce duplication of tests and facilitate the coordination of care.

But the real value in EHR, he suggests, is in the system’s potential output of information: “Cutting down the rate of dissemination of conventional information from 17 years down to months to weeks.” What he means, as I understand it, is that by having current findings – published data and recommendations – linked to a patient’s electronic chart and diagnostic codes, the doctors will see and (hopefully) read new materials having to do with their patients’ medical conditions.

Notes on Health Information Exchange:

This component of health IT relies on having a common language. “If physicians don’t speak the same language, their computers won’t either.” He emphasized the need for standard terms using this example: there are many ways to say “high blood pressure” in English; for a health information exchange to be functional, we need to agree on one term and use it.

“Information exchange is a team sport,” he considered further. “It’s a challenge, and we’re not always good at voluntary collaboration.”

Next, he listed some HIE essentials:

– a vocabulary and statistics (I’m not sure why these were paired as he spoke);

– a way of packaging information that it can travel on the Internet;

– electronic directories, so information goes where it should;

– protocols for delivery;

– security in transit.

What will it take to get physicians on board with this kind of plan? “We need economic incentives, trust, and requirements,” he indicated. Mandates might, in the future, involve licensing boards and other accrediting agencies that would test physicians’ competency in HIT. In his view, managing electronic information is an essential skill for doctors to provide effective medical care.

Notes on Clinical Decision Support:

First, he listed the four elements – algorithms, statistics, guidelines and institutional policy – that can be incorporated into CDS to promote evidence-based practice.

Second, CDS allows for Computerized Provider Order Entry (CPOE). This is a huge benefit at several levels, but the surprise for some in the audience is that the process becomes an opportunity for continuing medical education (CME).

(The idea for doctors’ learning as they enter orders, which I think important, is this, and  I’ll provide my own example here: if you’re a physician about to order a drug, like a new antibiotic for a patient who’s got liver failure, the computerized system might have a pop-up message that says “are you sure you want to order that? Antibiotic X is metabolized by the liver…” And so you’d learn that the new antibiotic X is metabolized by the liver, and you might then look over a readily-accessible table of alternative antibiotics.)

“This caught my interest because it doesn’t diminish physicians’ autonomy,” he said. It just enables them to make decisions for their patients in the context of additional, current information. “The end goal is not to adopt technology, but to improve care.”

Notes on Meaningful Use:

He listed “five pillars of meaningful use”:

1. patient and family enlightenment

2. coordinated care

3. quality, safety and efficiency

4. privacy and security

5. improved public and population health

Then the discussion turned to some big money questions – including a critical issue having to do with companies competing to develop better EHR systems and physicians’ incentives. If you’d like to read more details about meaningful use, I recommend a recent perspective in the New England Journal of Medicine and a brief in the August issue of Health Affairs, to which Blumenthal referred during his informative talk.

As for me, I’m tired of clipboards. I look forward to expanded health IT and EHRs. In the future, patients will be more informed in their decisions, and doctors will be in theirs. Maybe, sometime…

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Doctors Not Using Email Like It’s 2010

There’s been a recent barrage of med-blog posts on the unhappy relationship between doctors and electronic communications. The first, a mainly reasonable rant by Dr. Wes* dated August 7, When The Doctor’s Always In, considers email in the context of unbounded pressure on physicians to avail themselves to their patients 24/7. That piece triggered at least two prompt reactions: Distractible Dr. Rob’s** essay on Why I Don’t Accept eMail From Patients and 33 Charts‘ Dr. V on The Boundaries of Physicians Availability.

Perhaps the most astonishing aspect of these three guys’ essays is that, in 2010, there’s still a question about whether doctors should use email to communicate with patients. It’s hard for me to imagine physicians – including bloggers – so disconnected. But many are.

Last year, I had the opportunity to speak with Professor Nathan Ensmenger, a historian of technology at the University of Pennsylvania who’s studied physicians’ use of the Internet and email. Physicians aren’t luddites,” he told me. “On the whole, they’re a computer-savvy group, among the first to use the Internet in research and for professional development.”

Ensmenger contrasted doctors’ hesitation to take on email with patients with their early espousal of the telephone, which facilitated their practices and care in the early 20th Century. Doctors might want to work on-line, he suggests, even out of self-interest: the asynchronous nature of email, by contrast to telephone calls, affords more flexibility and workload control. Published studies, including an early 2004 report in the British Medical Journal, cite evidence  that an overwhelming majority of patients would welcome the chance to communicate with doctors by email. Nonetheless, many medical providers refuse to email patients.

Here’s a partial list of reasons why some doctors are reluctant to get on board with this (1990s) program:

1. Physicians don’t get compensated for time spent emailing patients.

2. Any written communication with a patient, or about a patient, is a potential liability that might be used in a malpractice suit against them.

3. There might be a breach of patient’s privacy if the email is not sufficiently secure, encrypted, or is accidentally sent to the wrong person.

4. Email is a time sink, dragging physicians further down the slippery slope of doing more, undervalued work.

Each of these points has some merit, I admit. I am most persuaded by Dr. Wes:

…This is not a new trend. We saw a similar situation years ago with the advent of the digital beeper. Even the most basic of private bodily functions in the bathroom could be interrupted at a moment’s notice. The expectation that phone calls should be returned instantly grew from this – personal context be damned. Doctors were accepting of these intrusions, however; the feeling of being omni-present, omni-available, and omni-beneficent fit nicely with the Marcus Welby, MD psyche of the time…

So the problem is that doctors are human, i.e. we have limits. Which of course isn’t a problem, but a good thing. I don’t particularly care for robotic physicians.

I’m not sure how to resolve this, but here are my thoughts:

1. About the compensation issue – I think physicians should be salaried rather than paid per unit of work. Communication is an essential part of what physicians do, and so this type of task should be included in their designated workload – whether that’s part-time or full-time.

2. About liability – we need medical malpractice reform, sufficient such that physicians aren’t afraid to write messages to people who are their patients.

3. About privacy – this seems a relatively bogus excuse. Compared to faxing, email is far superior in regard to privacy. And, as many others considering this issue have pointed out, we’ve learned to trust internet-based communications for other critical matters such as bank accounts, credit cards, etc.

4. About physicians’ time – this is a critical issue that hits close to home. Unless the health care system evolves so that mature doctors can carry out expert, interesting and careful work with reasonable hours, few bright young people will choose careers in medicine, and more seasoned physicians will have to stop practicing to protect their own health and well-being. And then we’ll all lose out.

So I don’t think that physicians shouldn’t use email – they should. But the system needs adapt to the 21st Century.

*Westby G. Fisher, M.D. is a cardiologist who blogs as Dr. Wes;

**Robert Lamberts, M.D. is a primary care physician who blogs on Musings of a Distractible Mind;

***Bryan Vartabedian, M.D. is a pediatric gastroenterologist who supplies 33 Charts.

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Back to Basics – But Which Ones?

A front-page story on the Humanities and Medicine Program at the Mount Sinai School of Medicine, here in Manhattan, recently added to the discussion on what it takes to become a doctor in 2010. The school runs a special track for non-science majors who apply relatively early in their undergraduate years. Mount Sinai doesn’t require that they take MCATs or the usual set of premedical science courses – some college math, physics, biology, chemistry and organic chemistry – before admission.

The idea of the program is two-fold: first, that the traditional med school requirements are a turn-off, or barrier, to some young people who might, otherwise, go on to become fine doctors; second, that a liberal arts education makes for better, communicative physicians and, based on the numbers published in a new article, a greater proportion who choose primary care.

Today Orac, a popular but anonymous physician-scientist blogger, considers the issue in a very long post. His view, as I understand it, is that if doctors don’t know enough science they’ll be vulnerable to misinformation and even quackery.

On the side of the spectrum, perhaps, Dr. Pauline Chen, a surgeon who puts her name on her blog and essays. In a January column, “Do You Have the Right Stuff to Be a Doctor?” she challenged the relevance of most medical schools’ entry requirements.

I see merit on both sides:

It seems fine, even good, for some students to enter medical school with backgrounds in the humanities. Knowledge of history, literature, philosophy, art history, anthropology and pretty much any other field can enhance a doctor’s capability to relate to people coming from other backgrounds, to recognize and describe nonparametric patterns and, perhaps, deliver care. Strong writing and verbal skills can help a doctor be effective in teaching, get grants and publish papers and, first and foremost, communicate well with patients and colleagues.

Still, there’s value in a doctor’s having a demonstrated aptitude in math and science. Without the capacity to think critically in math and science, physicians may not really understand the potential benefits and limitations of new medical findings. What’s more, doctors should grasp numbers and speak statistics well enough so they can explain what often seems like jumbled jargon to a patient who’s about to make an important decision.

Thinking back on my years in medical school, residency, fellowship, research years and practice in hematology and oncology, I can’t honestly say that the general biology course I took – which included a semester’s worth of arcane plant and animal taxonomy – had much value in terms of my academic success or in being a good doctor. Chemistry and organic chemistry were probably necessary to some degree. Multivariable calculus and linear algebra turned out to be far less important than what I learned, later on my own, about statistics. As for physics and those unmappable s, p, d and f orbitals whereabout electrons zoom, I have no idea how those fit in.

What I do think is relevant was an advanced cell biology course I took during my senior year.  That, along with a tough, accompanying lab requirement, gave me what was a cutting-edge, 1981 view of gene transcription and the cell’s molecular machinery. Back then I took philosophy courses on ethical issues including autonomy – those, too, proved relevant in my med school years and later, as a practicing physician. If I could do it again, now, I’d prepare myself with courses (and labs) in molecular biology, modern genetics, and college-level statistics.

My (always-tentative) conclusions:

1. We need doctors who are well-educated, and gifted, in the humanities and sciences. But for more of the best and brightest college students to choose medicine, we (our society) should make the career path more attractive – in terms of lifestyle, and finances.

(To achieve this, we should have salaried physicians who do not incur debt while in school, ~European-style, and who work in a system with reasonable provisions for maternity leave, medical absences, vacation, etc. – but this is a large subject beyond the scope of this post.)

2. There may not be one cookie-cutter “best” when it comes to premedical education. Rather, the requirements for med school should be flexible and, perhaps, should depend on the student’s ultimate goals. It may be, for instance, that the ideal pre-med fund of knowledge of a would-be psychiatrist differs from that of a future orthopedist or oncologist.

3. We shouldn’t cut corners or standards in medical education to save money. As scientific knowledge has exploded so dramatically in the past 30 years or so, there’s more for students to learn, not less. Three years of med school isn’t sufficient, even and especially for training primary care physicians who need be familiar with many aspects of health care. If admission requirements are flexible, that’s fine, but they shouldn’t be lax.

Critical thinking is an essential skill for a good doctor in any field. But that kind of learning starts early and, ideally, long before a young person applies to college. To get that right, we need to go back to basics in elementary and high school education. If students enter college with “the right stuff,” they’ll have a better understanding of health-related topics whether they choose a career in medicine, or just go to visit the doctor with some reasonable questions in hand.

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