Truth or Consequences in American Medicine, 21st Century Version

The New York Times has been a source of wonder and amusement to the Phantom lately, with regard to medical stories:
1. November 23:  Dr. Elizabeth Stier, a faculty member of the division of Obstetrics and Gynecology at Boston Medical Center, who is doing research on anal carcinoma, a disease which affects both men and women,  was recently notified by the American Board of Obstetrics and Gynecology they will decertify her as a board certified gynecologist if she persists in treating men,  as part of her research study. In explaining the board's stance, Dr. Kenneth Noller, the board's director of evaluation, provided a stunning explanation: "There were plenty of other doctors available to provide the HIV-related procedures that some gynecologists had been performing on men." If Dr. Stier persists treating patients regardless of their gender,  she will be defrocked, excommunicated from the club of certified gynecologists and possibly condemned to wander for all eternity in darkness. The board has not decided about wandering in the darkness yet.

2.November 24:  In the business section of the NY Times an article about the marketing of testosterone therapy directly to the public. Pictured and quoted in the story is Dr. Harry Fisch, a urologist, "who likes to say a man's testosterone level is 'the dipstick' of his health," and being a urologist, one might expect he might know about dipsticks, but he clearly does not know about testosterone.

  Fortunately, the Times has found someone to quote who may actually know of what she speaks, from  Georgetown School of Medicine, who, commenting on the advertising blitz said, "Do you feel tired after dinner?  Depends on how long after dinner. We all do eventually. It's called sleep."  

The article focused not on the truths we think we know about testosterone deficit as a disease in men, but on the marketing, the income derived--$2 billion dollars  in 2012, up from $324 million ten years earlier, after a $107 advertizing blitz by the drug makers, a nice return on investment. Of course the business types at the Times were either not interested or not qualified to judge anything about the basic truth of whether or not men are being treated for a real disease, i.e., for a true deficiency state,  or simply being sold snake oil. All that matters to the drug makers and the MBA types is the game: The FDA forbids the drug companies from trying to sell testosterone to men who are not truly deficient, but it does not forbid medical doctors like Dr. Fisch from becoming the pitch men for the product. If Dr. Fisch or a whole legion of like minded doctors want to prescribe Androgel, well, that's not the drug company's fault. They can't stop people from wanting their product. They just collect the money.

Any doctor can say anything he wants about testosterone, unless of course he is a board certified gynecologist, in which case he (or she) may be de certified and condemned to wander in darkness for all eternity.

3.November 24:  Mary Lou Jepsen, writing in the NYT Review, tells her harrowing tale of having a pituitary tumor which was misdiagnosed and mistreated, "only partly because of the shortage of endocrinologists, doctors who specialize in the hormonal systems." 

She tells us, "Without the ability to fine-tune my hormones and neurochemicals I believe I would have been trapped as a near-imbecile, wheelchair-bound, in my mother's basement for an abbreviated and miserable adult life. But with this ability, I have reached the top of my field. Still, the health care system hinders my acces to the chemicals I need to live. I am far from alone in this situation. It's time we changed the system."

Now, the Phantom has a special affection for endocrinologists, but he was disquieted when he got to the part where Ms. Jepsen says, "This all changed when I finally found a doctor to work with me to reconstruct my personality and my health by tuning combinations and doses of these powerful chemicals." 

Oh, oh, oh. And what kind of "endocrinologist" could do this? The Phantom lives in New Hampshire, where there are things called "naturopaths" who live under bridges and prescribe all sorts of things--eye of newt, testosterone, clomiphene--and they usually sell these out of the snake oil chest in their offices at substantial profit, and oh, my, my.  If truth is the first casualty of war, then truth is also the first casualty of the desire for financial profit.

The editors of the NY Times, did not call the Phantom for his opinion about the medical history Ms. Jepsen provided. The Phantom would have said, "Whatever this unfortunate lady had, it is dead certain what made her better was not any fine tuning of hormones and neurotransmitters."

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Here's a truth for the blogging public: There is, in fact, a huge revolution in American medicine and it has nothing to do with endocrinology, or testosterone or urology or gynecologists treating males with anal cancer, or with any science at all. It is contained in the observation that somewhere north of 90% of American doctors are now employees, file W-2 forms, and work for large corporations, "voluntary" hospitals, incorporated medical groups, the government or academic institutions. 

That, more than any scientific breakthrough, more than unraveling the human genome, more than any drug, more than startling advances in surgery (like laporoscopy) or in imaging (MRI's, ultrasounds) or in "personalized medicine," and certainly that, more than Obamacare,  has in fact, "depersonalized" medicine.

If your doctor is an employee, he likely has in his (or her) contract a clause which explicitly states that any patient he sees, (i.e., you) is the property of the corporation/ employer,  not the physician. That means, among other things, if the doctor leaves the practice he may be forbidden from "soliciting" you to be his patient.  He may run away from you in terror, should you track him down and show up in his new waiting room, for fear his former employers will direct their large in house corporate lawyers to drag him into court for "solicitation."  (And we are not talking about a misdemeanor, and a quick mug shot here.) He can only treat you if you manage to track him down all by yourself, which, given restrictive "non compete" clauses in his contract,  may mean he cannot practice any where within 20 miles of his current location. 

Think about that a little. 
Your doctor and you are not in the room alone. 

What's Eating American Healthcare? Obamacare Is The Least of It

An Effective Leader

If a hurricane followed by twelve tornadoes ripped through the state of New Hampshire tomorrow, some people would blame it on Obamacare.

The fact is, medical care is changing in ways which are not (yet) apparent to the consumers of health care, and only a small proportion of those changes is going to be affected by Obamacare.

Which is not to say the health insurance industry has not been a major force in the changes. Health insurance, the money people have driven doctors off the field over the past ten years. Nationwide only about 10% of doctors are self employed, independent, hang-out-your-shingle free market, Ayn Rand control your own destiny figures any more.

Most doctors are employees of either large corporations (hospitals, Kaiser type organization, commercial companies like Hospital Corporation of America, or large group practices). 

Insurance companies, and to a much less extent, Medicare, have so reduced payments to doctors, the vast majority found they could no longer pay their rent, meet their payroll and earn a living, so they flocked to employed status.

What they found when they arrived is that their new masters demanded more and more patients seen per unit of time.  

Administrators began to break down the tasks doctors do during their day, and dividing up these tasks to be done by high school graduates. Need a skin biopsy--have the dermatology tech do that. Costs less.  Need a stress test, a chest tube, almost any in office procedure, hire a tech. Need a visit to adjust your insulin doses?  A certified diabetes educator, might be a dietician, can do that. Need your coumadin dose adjusted, a nurse can do that.

What has been left to the doctors, the administrators argue is the stuff only the most expensive member of the team can do--read the X ray, listen to the history and order the diagnostic tests and the medication or the referral.

So far, all this, it may well be argued, increases efficiency and decreases costs.

Except when it doesn't:  Nurse practitioner and physician assistants now see patients for things like possible hyperthyroidism, angina, inflammatory bowel disease, multiple sclerosis, Lyme disease, peripheral vascular disease, and they often order the wrong or most expensive tests which means we are in the position of being penny wise, (cheaper visit) but pound foolish (unnecessary referral to a consultant $500, $4000 MRI, visit to the ER $1000).

"Medicine is too important to be left in the hands of doctors," was the jarring line of the 1970's. It was very punchy and anti authoritarian and it was widely quoted, almost a mantra.

Trouble is, that line has turned into a policy. Now the doctors no longer have much at all to say about how medicine is delivered.

It hasn't been and won't be pretty.

Yesterday, the Phantom met with the CEO of his hospital and a number of administrators from the corporation which runs the practices connected to the hospital.  These practices "feed" the hospital system. They send patients, laboratory, radiology referrals to the hospital. They, in business terms, bring the customers through the front doors.

 The CEO  said the purpose of the meeting was to open communication between the doctors and the administration. When the doctors started talking about the problems the practices were having, about the loss of critical doctors, about why they could no longer refer patients to the hospital, or send them to the emergency room,  the CEO of the hospital said she did not want to hear about those problems. 

She had problems of her own. She had not been able to meet her budget for the past 3 years. The doctors had been trying to tell her about why they were sending fewer and fewer patients across the street to the hospital, but she did not want to hear about any of that, she said. The problems in the practices across the street referring to her hospital were not her problems, she said. The practices belonged to another administrator. All she cared about was the hospital.

"So, if you manufacture cars, and the dealerships which sell your cars all over the country are closing down, that doesn't bother you?" someone asked. "All you care about is what is happening in your factory?"

The CEO did not get the analogy.

Finally, one doctor said, "Can you hear yourself? Don't you hear what you are saying?  You are saying you are here today to establish communication, but you do not want to hear anything we are saying. Is there something wrong with this picture?"

She did not understand that comment and she went on to say she thought we needed to set up a committee to improve communication with the doctors. 

One of the other administrators noted doctors do not attend the committee meetings because they are not paid for committee meetings and they insist on seeing patients, for which they get RVU credit toward their pay checks.

Eventually, the patients will feel it. Right now, it's just the doctors.

The Trouble with Experts

The New Yorker ran an article about the experiments with legalizing marijuana in Colorado and Washington state, quoting extensively from a man who has made a living as a "drug policy analyst," a professor at UCLA, Mark Kleiman.

The message the Phantom took from Professor Kleiman is that drug policy is very complex and is not for dilettantes and uninformed citizens, not to mention state or federal legislators to dabble in without consulting real experts like himself.

The Phantom emailed Professor Kleiman with the observation that in the 1960's as college students shifted from alcohol to marijuana, alcohol consumption clearly declined. To his great credit, the professor took time to respond to an unsolicited email from out of the blue and he noted this phenomenon may not apply today, especially in laboratories which are not limited to college campuses but to entire states. 

He also remarked that "only" 20% of Americans in prisons are there for drug offenses, and these are usually not for possession but for selling drugs.

The Phantom questioned this number, noting it didn't sound right, didn't pass the smell test, and the professor, predictably, said this is because the Phantom didn't want to believe hard numbers which conflicted with his own biases and beliefs.

As the Phantom considered his own less than rigorous approach to this area over which Professor Kleiman claimed to have a firm grasp, he googled "drug possession arrests" and noted one American is arrested for marijuana possession every 42 seconds and there are over 700,000 arrests for marijuana possession alone ever year in this country.  Those arrested are thrown in "jail." They may not go to "prison" but is being incarcerated in jail not being imprisoned?  

The "data" over which Professor Kleiman claims mastery say that only one out of five prisoners in state or federal penitentiaries are there for "drug related" offenses, mostly selling drugs. That data is likely culled from the databases from courts, which may separate out what people are sentenced for effectively. But these data do not, presumably, include all those citizens who are arrested, jailed, released, summoned to court, otherwise detained.  These detainees are also violated, if more briefly, and the damage done to the relationship of a citizenry and its government as personified in the police force is still significant.

Including in the data set all those arrested/ jailed  would make legalization of marijuana seem more compelling.

Data is funny that way. You have to look afresh at numbers and think about what other numbers might be relevent sometimes to get a real feeling for what it means. 

The psychology of the expert is often at play here, too. The Phantom could readily see in the professor's response his disdain and anger over the audacity of a layman to question his authority. When the Phantom told him the 80% figure was a red flag in medicine for a figure not backed by hard data he reacted in anger and said doctors may throw around numbers without adequate knowledge but that is not true in his field, populated by real scientists.  He knows what he knows; it's the rest of the world which isn't listening to his erudition, which cannot see the complexities, which is wedded to rigid beliefs unsupported by the data which is the problem. 

But, like doctors who finally had to respond to the questioning by laymen who had access to information on the internet, the professor may have to, eventually, concede his reading of the data may be as narrow minded as those he accuses of the same thing. 

After all, as one can see immediately on the net, is the proposition that "only" one out of five prisoners across state and federal institutions is there on drug charges, for that 20% serving time, that is a very significant thing. Over 300,000 souls in prison for drug offenses. Some may be the Avon Barksdale's and some the lietenants, but some are the pawns in the game.  If they weren't there for selling drugs, they might be there for brutalizing fellow citizens in whatever illegal activities remain after drugs are legalized, it's true, but at least we will have incarcerated people for something that should be a crime, not a public health problem.

 

Jiffy Lube Medicine: The MBA's Take Control of Medical Care

You take your car in for an oil change and the guy who changes the oil knows only how to change oil. He is not a mechanic, because the oil change place does not need to pay a mechanic's wages to a guy who does  just one thing: change the oil. He does not--cannot--look at the brake pads,  notice the axle and wheel bearings are worn, notice the nail in your sidewall which will blow out the next time you exceed 60 MPH,  inspect the parts of the car which, if they fail, can kill you. You may natter on to him about the fact that when you turn the wheel hard, you get a shuddering and a whining which, if you knew more, or if he knew more,  might suggest your steering is about to fail. So you can drive out in your car with new oil and a whole host of lethal pathologies, undetected.

Your oil is changed and you are out the door, and you judge the experience by the amount of time you had to wait to have your oil changed and the price.

Current models of providing medical care are designing the office visit to be a sort of Jiffy Lube medical experience: Get in, get out. One task at a time. Pay and go.

The managers of medical practices are now designing their systems the same way. The endocrinologist is told not to waste his time adjusting his patient's insulin doses--let a lower paid, limited skill worker do that for a dozen patients--the physician's assistant (PA)-- who can look at the data from the computer download of the patient's home glucose testing device, write the insulin prescriptions, make some adjustments to the insulin doses,  and get the patient out the door. Change the insulin like changing the oil. Pay and go.

If you were that patient, you may have seen your "internist" last week, where you were seen by another physician's assistant, who wrote prescription renewals, but never had you take your shirt off, never listened to your heart or lungs. That PA had renewed your prescriptions for your blood pressure and for your cholesterol. Ten, twelve minutes, pay and go.

That PA did the job the MBA who designed the practice wanted done: The PA moved that patient in and out of a room in 12 minutes, generated a bill and moved on to the next patient. In an 8 hour day, at 12 minutes a patient, that's 40 patients a day. This is the Holy Grail of MBA run medical practice. Maximizing "productivity."  AKA maximizing "efficiency."  AKA minimizing wasted effort.

Of course, neither physician's assistant had you take off your shirt, so neither has looked at your skin, so they missed the melanoma on your shoulder, and neither has had you take off your shoes and socks, so they miss the swelling in your feet, and neither picks up the fact there is a nail head flush with the sole of your foot, a nail you cannot feel because you have neuropathy in your feet, because your feet are your podiatrist's job.   Neither PA has examined your eyes with an opthalmooscope, because that's your opthalmologist's job. Neither has phoned your cardiologist to ask whether you were in atrial fibrillation at the last visit, because neither listened to your heart, so neither picked up the fact that you had slipped silently into atrial fibrillation, for the first time in your life.

A week later, the undiagnosed atrial fibrillation in your heart results in a the formation of a clot in your left atrium, which plops into the left ventricle and gets catapulted to your brain, but you are lucky because it goes to the right side of your brain, rather than the left side where the speech center is, so you can still speak, although you cannot move your left arm or leg.

But, fear not, you have had efficient, state of the art medicine,  standard of care, from "providers" who are highly "productive."

If you had had a real doctor exam you, if he had taken 30 minutes, instead of the 12 minutes the PA's spent with you, you would be walking  today. That foot with the nail would not have had to get amputated. And, oh yes, the melanoma which has silently metastasized to your brain and lungs and which will kill you in two years, that might have been discovered at a curative stage,  if a real doctor had examined you. But missing that was not your endocrinologist's fault, nor the fault of his PA. Examining your skin, doing a "mole patrol," is the job of the dermatologist. 

Luckily, you have been well served by the new highly productive medically efficient form of practice:  You will not have to suffer long hobbling around on one foot, half your body paralyzed; your misery will be short lived because the melanoma will claim you quickly.


We now have efficiency in medicine, as defined by the MBA's and as administrated by the MD's with MBA's who were once obstetricians or anesthesiologists,  but are now burnt out,  and they are running hospital owned physicians' practices in areas where they have never practiced, and they are calling the shots for men with prostate cancer and people with diabetes, hypertension, cholesterol trouble and kidney, eye and nerve disease caused by the diabetes.

We have medical practice orchestrated by people who would not know good medical practice (as we were taught it  in the days of the dinosaurs) if they tripped over it.

We have medical practice which is very efficient from the perspective of the people billing for the services:  Each task has been identified, given a billing code and the insurance companies billed electronically and the payments made.  Ever code is accurate and everything is done according to the billing rules. Nothing is done according to the rules of good medical practice, as those rules were developed in the medical schools of yore.

From the patient's perspective, maybe things are not so efficient. You need to schedule ten appointments,  where before you needed only one. You need to travel, wait in the waiting rooms, ten times and even then, since each practitioner is focusing on only one ten centimeter part of you, things get missed. You needed an appointment with the eye doctor, the kidney doctor, the heart doctor, the dermatologist, the endocrinologist, the pain doctor, the orthopedist, the neurologist, the neurosurgeon.

Costs to the medical system as a whole have not diminished as a result of this approach, of multiple billings and multiple visits,  but the accounting ledgers of the people with MBA's running each of these practices have been mightily improved.

We do not have the best medical practice money can buy in this country, just the most expensive medical care.

It's not President Obama's fault.  It is difficult to identify who is at fault. There is not just one villain. There are simply people exploiting the game, making money, doing more harm than they know and more harm than they even care to know. They are just doing their jobs. Just following orders. Innocent gamers. Don't blame them.

Heaven help us all. 

Breaking Bad And Pop Culture

Okay, the Phantom has his biases, like anyone else. 
The Phantom refused to watch "Breaking Bad" because he did not like the whole premise:  A man with terminal cancer, determined to provide for his family, cooks up drugs to make a quick fortune.

A timid suburban school teacher entering the world of drugs and cartoon bad guys, the worm has to turn, and must prevail by sheer cunning and resourcefulness. Let's see, there was the local housewife who sold drugs; it seems a whole genre of fearful, bourgeois, who find themselves in financial distress, who turn to a fearsome, deadly world for which they are not prepared and you root for them to survive and prevail because you feel so sorry for them.

After three or four episodes, the Phantom was still groaning, but his wife and a friend who loved "The Wire" (therefore had street cred for good taste) prevailed. Keep watching; it grows on you.

And it has grown on the Phantom.  The premise is still a groaner, but there are scenes which are so well done, and the plotting of the story lines so meticulous, the show, it must be admitted, has enough merit to almost balance its Hollywood pitch room premise. 

What it does so well relates to the science, the chemistry, the medical scenes. The episode in which we have been led to believe Walter White is not responding to his chemotherapy and then, in a surprise you could not see coming, it turns out he has had a substantial response, was set up so carefully, one had to be amazed. And the depiction of the experience of being a cancer patient, the experience of the family, the rising hope, the dread with each CAT scan--is the cancer smaller or still growing? And the joy at the small victory--oh, the tumor is smaller this time. Let's go party. Drink champagne. Families do that. They enjoy the small, the current good news because the news can only be good briefly, but they allow themselves to believe, because what else do they have?

The chemistry has also been wonderful, as Walter teaches a principle in class, and he relishes the beauty and power of chemistry, and then you see how he uses it to blow up a lock and steal the makings of his product, or how he rescues himself and his feckless sidekick, Pinkman, by fabricating a battery to start their RV and get them out of the desert.  

The bad guys are very very bad and amusing. Cartoons. The Irish lawyer who chooses a Jewish sounding nom de guerre because street hoods think Jewish lawyers are smarter, is a hoot. 

So it is around the edges the series succeeds:  wonderful plotting, not losing track of threads, making sure mis steps and character weaknesses result in trouble down the road, scenes in which real science is shown to have real power, and the insistence that every single scene is taut with dramatic tension keeps you watching. It's great fun.

But nowhere is any real social commentary, any effort to get you to see the world differently.

There are characters who do things which ring true: Walter's wife reacts exactly as one would expect someone like her to react, and for the Phantom she is the most real and instructive character in the series thus far. The Phantom has heard she is reviled out there in TV land. Fans love to hate her. 

The Phantom finds this bewildering. She hates being lied to, and she has good antennae for lying. She bullies her husband into accepting chemotherapy despite his very reasonable objections. She uses her attractiveness to get a job, although it is pretty clear she may be setting herself up with her boss for an affair, which she may try to leverage into financial security down the road. But she clearly cares for her husband, and is overjoyed at the news he's responded to chemotherapy. 

Maybe she breaks bad later, but so far, Mrs. Walter White is just fine with the Phantom.

What is depressing is that good writers have to take the easy road to developing a story: Hey, let's do a mild mannered high school science teacher who uses his science to make drugs and launch a career among the bad guys, who he keeps at bay with his magic scientific tricks.  See, and he gets braver and braver, and he realizes that what was really making his life a misery was his own fearfulness and all he has to do is brave up and make things explode to find happiness.

Give that show a slew of Emmy's.