Category Archives: Culture

Should we die like doctors do?

The Saturday Evening Post has published a provocative article (How Doctors Die) by retired physician Ken Murray, making a strong case that over-treatment is rampant at the end of life. He describes anecdotes of physicians serenely accepting their death sentences and making the most of their last months and weeks compared with the average person who suffers needlessly and racks up a big bill in the process. Doctors understand the limitations of medicine in ways that typical patients don’t, he says, but have not been in a position to provide more appropriate care due to patient pressures, legal concerns, and the nature of the medical system. Hospice patients may live longer anyway, he adds.

I’m mainly on Dr. Murray’s side. I believe that over treatment is a big problem and that hospice care is underutilized. I understand the concept of never wanting to be put on life support. I am angered and saddened that the nonsensical “death panel” argument was used as a cudgel against ObamaCare by invoking the prospect of rationing of care.

And yet I’m uncomfortable with the article. First, to what extent should we accept the author’s anecdotes as evidence of the general state of physician perspectives? I don’t see a lot of systematic evidence for his contentions. Second, even if doctors feel that way should patients necessarily ratchet down their demands for services? I would say no.

My concern as a patient, caregiver or family member is about being written off when it’s not warranted. For example (since anecdotes seem ok, here) doctors discouraged a family member from chemo for leukemia due to his age, even though as I discovered the advice wasn’t really evidence based. He had chemo anyway thanks to our insistence, tolerated it well, and lived an extra year. It’s hard to figure out what tradeoff is reasonable to make between suffering and the potential to extend life even when all the information is in hand, which it rarely is.

And while it’s easy to oppose heroic, frequently futile measures and suffering in general, when it gets down to specific situations I’m not nearly as comfortable. Who’s to say a patient shouldn’t be willing to suffer in order to live a while longer and have a few more weeks or months with their grandkids?

The general point of the article –that those with the most knowledge of the limits and possibilities of medicine seek less of it than the general public in certain circumstances– is certainly worth contemplating. But I haven’t changed my own views after reading the piece.

Who’s in the dark about complementary therapies?

When I saw the MedPage Today headline, “Study: Docs in dark about complementary therapies” I assumed it meant that doctors didn’t understand these therapies. But the story described patients withholding information about what they were doing from their physicians. That’s not exactly a new or surprising finding.

The study advises physicians to ask about what else patients are taking or doing, which is probably a good idea. But I’d like to see more attention paid to how physicians react when they hear about other therapies and the extent to which they are willing or able to engage with the large percentage of patients that seek relief or cure outside the medical setting at the same time they are working with their doctors.

Some of these therapies are herbs or other substances that may interact with prescribed drugs. Doctors definitely need to know about that and deal with it. Other approaches, such as massage, meditation and reflexology may be helpful for some patients –and it may or may not matter if the physician is involved.

The best physicians take a personalized, holistic approach to their patients, and do so in ways that do not conflict with the evidence based mantra.  One physician I know has a medicine man (who’s also his patient) perform a ceremony blessing the statin he prescribes to another member of the same tribe. I’m willing to bet his patients are more adherent as a result of this approach.

I’m not a major proponent of alternative and complementary medicine, but I do find it revealing to see how physicians relate to other approaches, especially for diseases they can’t cure. Do they insist that other approaches are invalid and consider them an affront? Do they balance a healthy skepticism with open mindedness to the idea that they don’t know everything? Do they vary their approach depending on the individual patients and their situations?

 

Choosing better, US style

Short White Coat blogger Ishani Ganguli marvels at a frank UK ad (advert?) discouraging people with non-serious illnesses or conditions from clogging up the emergency room. It shows a line of people who shouldn’t be there. At the end is a wreath, representing a heart attack victim who should have been first in line.

She wonders aloud why we couldn’t have that kind of campaign here and answers that problems include access to primary care, the perception that going to the ED would be quick, and that primary care referred them to the ED.

These factors are all legitimate, but there’s more to the story. Emergency departments can be profitable and are a major feeder for inpatient admissions, so hospitals advertise them. You don’t have that in the UK. That advertising also leads to the perception that the hospital is a better place to be seen, so even patients who could get access to their primary care physician don’t try.

My health plan (Blue Cross) and others have what are euphemistically referred to as “demand management” services. In my case I can call and speak with a nurse who can steer me in the right direction, whether toward self-care, the emergency department, primary care, a specialist or the pharmacist. I’m not sure these things really save the health plans any money, but I also don’t know whether the UK ads work.

 

What’s new at HIMSS? Airbnb

A lot has changed since the last time I attended the Healthcare Information Management and Systems Society (HIMSS) meeting a few years back, but the biggest difference in my own experience at #HIMSS13 had nothing at all to do with health information technology. Rather, the big change was that even though I could only book 10 days ahead I was able to find low cost lodging close to the event, thanks to Airbnb, which describes itself as “a social website that connects people who have space with those who are looking for a place to stay.” Airbnb used information technology and social networking to completely transform my lodging experience from what it was only a couple years back. I’d love to see health IT transform health care to the same degree and as quickly. And although I do not believe health IT companies can just copy Airbnb’s model, perhaps some of the same principles can apply.

Here’s how things worked for me:

About 10 days before the conference I decided to go. But with 35,000 attendees –many coming from Boston– there were no flights whatsoever on Sunday, March 3, when I was available to leave, even if I had been willing to pay $1000 one-way. So instead I got creative and booked a flight from Providence, RI to Gulfport, MS. That wasn’t ideal, and it’s the same thing I would have done a year or two ago. I decided to stay in Gulfport, then drive or take a cab 80 miles to New Orleans on Monday morning. No rental cars were available for that trip so a cab it was.

Lodging was another story, with a happier ending. Hotels anywhere close to the convention center were sold out, although I did find a room at the Hilton for $900. No thanks. A couple years back I would have found a room 30 or 50 miles away or looked for a friend with a place there. But I remembering hearing about Airbnb and decided to give it a try. There were several listings for individual rooms and even whole apartments and houses within 3 or 4 miles of the conference. Many individual rooms were under $100. I signed up for an account, which took very little time, then followed a number of steps designed to increase trust and safety: I verified my phone number, connected via Facebook, Twitter and LinkedIn. I filled out a brief profile.

I looked through the listings, which included photos, bios of the hosts, and lots of reviews by people who had stayed at the specific properties, as verified by Airbnb. Most reviews were pretty positive, but hosts had replied to negative ones and gone into detail. I got a much better sense of what I was in for than anything I’ve encountered in health care. I selected a room for about $80 (< 1/10 of the Hilton price) and tried to book it. I sent a message to my host explaining why I was coming and letting him know I was a nice guy. This host had a policy, enforced through Airbnb, of approving prospective guests before accepting them. According to the site, most hosts reply within a couple hours, but they have up to 24. When I didn’t hear back within 2 hours I selected another spot, advertised as Street Car to Jazz Fest/French Quarter, which allowed instant bookings. This place was only $60 for a private room plus another $10 cleaning fee and $8 for Airbnb itself. The hosts’ extensive description gave me a good understanding of the place, mentioned free Internet, restaurants within walking distance, etc. Reviews were generally quite positive –and although it sounded much more like my hostel experiences from 20+ years ago rather than my more recent travel preferences– I decided to go for it. Information on Airbnb showed that the hosts, Robyn and Amanda responded to 100% of their listings, response time was quick, and that they updated their calendar frequently.

I was also reassured my Airbnb’s 24/7 phone support and various safety and security tips and guarantees.

I’m glad I went the Airbnb route. My hosts and I communicated over the Airbnb website but I also was given their phone number and email address. We coordinated my arrival time, they offered me a parking spot (which I didn’t need) and when I got there they recommended a close by restaurant that met my needs and suggested a cab company. (It was United Cab, which didn’t show up even after I confirmed and re-confirmed, but that’s not my h0sts’ fault).

I met a young French couple that was staying there for a month, and there were a bunch of law students staying there doing volunteer work. They were downstairs, though, so not bothering me. I had a good night’s sleep and was on my way.

Airbnb released my $100 security deposit within 24 hours and sent me a message asking for a review, which I provided and is now published. My hosts also reviewed me, so future hosts can see what I’m like (laid back, according to my hosts). And Airbnb let me communicate privately with the company if I had concerns I didn’t want shared or posted. (I didn’t.)

As I wrote, Airbnb’s innovations don’t translate directly into health care. There are some companies, including Castlight and ZocDoc that apply certain aspects of the model, including transparency of data and ease of booking appointments. Newer companies including Informedika and par8o are applying some of the principles to physician consultations and referrals. But there is room for a lot more and I’m hopeful Airbnb and other consumer Internet innovators will be inspirations. In particular I’m hopeful that new approaches will provide an alternative approach for providers that don’t want to be parts of big organizations.

In the meantime, Airbnb itself is making a contribution to health care by reducing expenses and increasing convenience of conference goers like me. No doubt it’s also being used by families who need to travel to other cities for medical visits.

Bionic eye: seeing the future

FDA just approved an implant for certain people with severely limited vision. This “bionic eye” does not restore sight but it does help “detect light and dark and help [people] identify the location and movement of objects.” So it could be a big help from a functional standpoint for certain individuals, even though it’s far from perfect and may not be completely safe.

Fast forward a decade or two or three and imagine a time when implants (or some other approach) can restore vision to normal. That will be pretty cool for the many people whose vision is relatively poor and there will likely be a lot of demand for such treatments/devices, even from people that we would not consider visually impaired today.

But then imagine that the technology keeps advancing and gets to the point where technology can improve on natural vision, so that someone with a bionic eye becomes more like the Six Million Dollar Man, especially if they get enhancements not just to the eye but to other body parts as well. I’m in my mid-40s and have a reasonable expectation of living to the time when this moves from science fiction to reality.

If you think about it, we are already starting to get there in limited cases.  Oscar Pistorius, now infamous for other reasons, shows that a double amputee can be as fast or faster as Olympic runners. How soon until other Olympians –who already commit their lives and bodies to the pursuit of excellence– will want body modifications to improve competitiveness?

Obviously the path of medical technology will raise all kinds of ethical issues. It’s time to start the discussion.

If nurses were lawyers

It’s interesting to contrast the markets for new lawyers and new nurses and how those markets are portrayed in the popular press. Casual observers and reporters are willing to take it for granted that there is a shortage of nurses and a need to train a lot more of them. Students are responding by applying to nursing schools en masse and nursing schools are boosting enrollments. Reports that 43 percent of new nurses are unable to obtain jobs in the profession are explained away as recession related or irrelevant to the “looming” long-term shortage.

Lawyers are different. When it’s reported that only a little more than half of new law graduates get a job as a lawyer within 9 months of graduation, the Wall Street Journal rightly refers to a “lawyer glut.” Prospective applicants are getting the message and law school applications are down 30 percent since peaking a decade ago. On the other hand, those in the law school business are not giving up so easily. Nineteen law schools have been accredited since 2000 and several more startups are in the works. If these schools were smart they would take a page from the playbook of the nursing schools and support research to show why more lawyers are needed.

I’m not saying that the prospects for nursing jobs are as bleak as that for lawyers. But I do advise prospective students for any professional school to take a good hard look at job prospects before taking on a pile of debt and devoting several years to further schooling.

Call it a health insurance store or market instead of an exchange

I’m a health care expert who follows health reform closely, so when I’m confused about something I know most people are. When Massachusetts passed the universal coverage law in 2006 I didn’t understand exactly what the Connector was supposed to do. If they had called it a health insurance store or marketplace or comparison site I would have grasped the concept better. Once it’s explained it’s obvious, but why use the word “connector” in the first place?

The federal Affordable Care Act makes matters even worse. It calls these things health insurance “exchanges.” That word has the wrong connotations. When I hear the word “exchange” I think of a stock exchange. That’s not somewhere I go to buy or compare products or services to use. Others think of “exchange” as what they do when they made a purchase that was the wrong size or received a gift they didn’t like.

Even for health wonks that fully grasp the concept, the word “exchange” is confusing, because the term is also used in the context of health information exchanges, which are used to exchange clinical data. I often hear people asking about the impact of the “exchange” –without specifying “insurance exchange” or “information exchange,” and I have to ask them which they mean.

There’s a simple solution to this: let’s dump the word “exchange” and use a term that’s more understandable and appropriate. How about:

  • Store
  • Marketplace
  • Comparison site
  • Supermarket

The nursing shortage myth

For years we’ve read that the US faces a looming shortage of nurses. Shortfalls in the hundreds of thousands of nurses are routinely predicted. These predictions have been good for nursing schools, which have used the promise of ample employment opportunities to more than double the number of nursing students over the last 10 years, according to CNN.

Yet somehow 43 percent of newly-licensed RNs can’t find jobs within 18 months. Some hospitals and other employers openly discourage new RNs from applying for jobs. That doesn’t sound like a huge shortage, does it?

But the purveyors of the nursing shortage message have an answer for that. Actually two answers: one for the short term and another for the long term. The near term explanation is that nurses come back into the workforce when the economy is down. Nurses are female and tend to be married to blue collar men who lose their jobs or see their hours reduced when the economy sours, we’re told. Nurses bolster the family finances by going back to work –or they stay working when they were planning on quitting. There’s something to that argument even if it’s a bit simplistic.

The longer term argument is that many nurses are old and will retire soon, just when the wave of baby boomers hits retirement age themselves and needs more nursing care. Don’t worry, the story goes, there will be tons of jobs for nurses in the not-too-distant future. This logic comes through again in today’s CNN story:

Demand for health care services is expected to climb as more baby boomers retire and health care reform makes medical care accessible to more people. As older nurses start retiring, economists predict a massive nursing shortage [emphasis mine] will reemerge in the United States.

“We’ve been really worried about the future workforce because we’ve got almost 900,000 nurses over the age of 50 who will probably retire this decade, and we’ll have to replace them,” [economist and nurse Peter] Buerhaus said.

I don’t buy this logic. And I stand by what I wrote almost a year ago in Nursing shortage cheerleaders: There you go again:

My issue with the workforce projections is that they don’t take into account long-term technological change, but simply assume that nurses will be used as they are today. I’ve taken  heat for writing that robots will replace a lot of nurse functions over time. People seem to be offended by that notion and have accused me of not having sufficient appreciation for the skills nurses bring.

So let me try a different tack. Think about some of the job categories where demand is being tempered by the availability of substitutes. Here are a few I have in mind that have similar levels of education to nurses:

  • Flight engineers. Remember when commercial jets, like the Boeing 727 used to fly with two pilots and a flight engineer? Those planes were replaced by 737s and 757s that use two-member flight crews instead
  • Junior lawyers and paralegals. Legal discovery used to take up many billable hours for large cases. Now much of it is being automated
  • Actuaries. Insurance companies used to hire tons of them, but their work can be done much more efficiently with computers

I don’t know exactly how the nursing profession is going to evolve but I do notice that the advocates for training more nurses are typically those who run nursing schools rather than prospective employers of nurses, such as hospitals.

If you want to be a nurse, go for it. But if you’re choosing nursing because you think it’s a path to guaranteed employment, think again.

Mental health access is no substitute for gun control

I’ve been surprised at the upswell of support for increasing access to mental health services as an antidote to gun violence like we witnessed in Newton on Friday. I’m a big advocate of mental health care but just don’t see how anything we do in that arena would have prevented either of the last two mass shootings.

Accused Colorado killer James Holmes seemed to have plenty of access to mental health. According to Reuters he had been “under the care of a psychiatrist who was part of a campus threat-assessment team.” Meanwhile, Newtown shooter Adam Lanza lived in an affluent community, where a high percentage of residents have commercial health insurance that includes straightforward access to mental health services.

Access to mental health care did nothing to stop Holmes or Lanza, but access to high-powered weaponry enabled mass killings. It seems the case for reducing access to such arms is therefore a lot stronger.

Advocates of increasing access to mental health services would be wise to back away from using the Newtown tragedy as a springboard for their cause, especially when there are so many other sound reasons to  back mental health. Instead I would highlight how offering mental health services to people with depression can free up needed capacity in primary care and lower overall medical costs, and how improving mental health treatment can boost productivity and economic growth. There are also plenty of compelling arguments to make about the opportunity to improve quality of life for mentally ill patients and their families even if they are not as dramatic as preventing a massacre.

Why Massachusetts can afford universal health insurance

Health insurance in Massachusetts is more expensive than anywhere else in the country and yet the state is able to afford universal coverage. How can that be? An important part of the explanation is that the state values education, and a well educated population yields a highly skilled labor force with high incomes. Those high incomes can support health insurance coverage.

While the US as a whole is a laggard in education –scoring 25th among 34 countries in math, for example– Massachusetts students are world class. In science, Massachusetts is right up there with Singapore, and it does well in math, too where our students rank right below Japan and above Russia. This bodes well for future Massachusetts performance in technology and science fields, which are likely to be major drivers of the economy in the next generation (unless finance takes over everything). There’s no international comparison that I’m aware of for creativity, but I’m willing to bet Massachusetts would come out well there, too.

Achieving meaningful health care reform and universal coverage require more than just passing health care laws. Enlightened policy in multiple fields –especially education– is a critical enabler.