I had a recent conversation with an old friend about her elderly father that encapsulates a lot of what is both great and terribly wrong with healthcare in America today.
Here are the basic facts: the man is in his mid-80s, retired from teaching school, and is active and vigorous, living in the community; he is cognitively intact. He has a history of coronary disease and had an intracoronary stent placed some years back. He is asymptomatic on a typical “cocktail” of meds including aspirin, a statin, and an ACE inhibitor. Over the summer, he had a routine follow-up visit with his cardiologist, who detected a carotid bruit. After a duplex sonogram and a CT angio, a high-grade unilateral internal carotid stenosis was identified, and carotid endarterectomy surgery was recommended. My friend called me to see if I could recommend a surgeon in the city where she and her father both live.
Continue reading The Good, the Bad and the Ugly
I highly recommend a provocative essay by Ezekial Emanuel that appears in the October 2014 issue of the Atlantic. Dr. Emanuel is a prominent academic who has also held important positions in government, including as a Special Advisor on Health Policy to the Director of the Office of Management and Budget and National Economic Council. He is also the eldest of the three impressive “Emanuel Brothers” that also includes Rahm (former White House chief of staff and now mayor of Chicago) and Ari (a prominent Hollywood agent). His piece is entitled “Why I Hope to Die at 75.”
OK, so the title is a bit over the top and meant to shock, and it is not even entirely accurate. But the message is really worth thinking about. Emanuel sets out why he wants to avoid the typical American approach to aging and progressive infirmity; he does not want to join the ranks of what he refers to as “American immortals.” Instead, he says that when he hits the admittedly arbitrary age of 75, he will no longer actively seek to prolong his life. No more doctor visits, no more “preventive” measures, no more diagnostic tests, no more interventions. Done. Whatever happens after that, well, so be it.
Continue reading Over and Out
There is a growing awareness of the importance of health literacy – the extent to which patients and their families are able to understand words we speak and the written materials we provide. This is a good thing, since there is very good evidence that patients who have a better understanding of their condition and recommended treatment feel better, adhere better to recommendations, enjoy better health outcomes and rate the experience of their care higher. Oh, and they also sue for malpractice less frequently. The problem for providers is that it is not easy to get this right. Continue reading Health Numeracy
I have come to believe that fee for service (FFS), at least in its current incarnation, is an unsustainable model of financing health care. Pick up any newspaper or journal and you are likely to see that I am not alone. The reasons are as numerous as the faults of the present health care landscape – high costs, poor quality of care, unhappy patients, and unhappy providers. Continue reading Providers in the Insurance Game
I was invited to give a talk about “patient satisfaction” at a recent OB/Gyn Grand Rounds. I have written previously that “satisfaction” is a pretty low bar, and so I spoke instead about the patient experience. Continue reading Evaluating Physician Performance
Several medical journals that I receive (if not read) regularly have a section devoted to interesting images. The New England Journal has “Images in clinical medicine,” Circulation has “Images in cardiovascular medicine,” and the Journal of the American College of Cardiology has “Images in cardiology.” Each generally contains a short case description, along with one or more images – photographs of patients, histologic sections, radiographs, MRI images, and the like. Continue reading Images in Medicine
For years, I have been hearing about how new technology will transform every day clinical practice, and I have been looking forward to it. Who wouldn’t want to be able to understand better the basis of human disease based on the “new taxonomy” of precision medicine? Or offer personalized therapeutics based on full genome sequencing? Or have the ability to predict better which patient will decompensate based on advanced analytics? And yet… most of us are pretty much doing what we have always done – diagnosing disease based on signs and symptoms, prescribing drugs based on their likelihood of efficacy in a population that more or less looks like the patient in front of us, and waiting for patients to decompensate and then reacting to it. Yes, we are doing all this while using (struggling with?) an EMR, but still, the basics are all pretty much the same. Continue reading The Future Arrived for Me Last Week
I think I am like many practicing physicians in my “love-hate” relationship with clinical practice guidelines. On the one hand, it is often helpful to look up a set of evidence-based recommendations on a particular clinical issue, and I feel particularly fortunate that the American College of Cardiology and the American Heart Association have collaborated to produce high quality guidelines on a wide-range of subjects relevant to my practice. On the other hand, I am well aware of the shortcomings of practice guidelines, including the limitations of the underlying evidence base, the challenge of synthesizing the available evidence into guidelines, and the often limited applicability of recommendations to clinical practice. Continue reading Practice Guideline Overload
Everybody recognizes that the United States spends considerably more on healthcare than other “western” countries do. It doesn’t matter if you look at per capita expenditure or percentage of GDP spent on health services, we rank at the top by a large margin. Of course, how much we spend is only part of the story. If, for example, we enjoyed better care and, as a consequence, better health, then one might conclude that all that “extra” money is worth it. The story line would be: we live in an affluent society, and we choose to spend a large portion of our wealth on healthcare to enjoy the added benefits of better health. Most observers have concluded, however, that we don’t enjoy better health than our western European friends, and so conclude that health care fails to deliver value – we are spending more than others, and not getting any measurable benefit. This is one of several arguments (I hope to address others in upcoming posts) for the need to lower health care expenditures in the US.
I agree that we spend more on healthcare than we need to, but it is important to consider that population health measures like life expectancy at birth, or rates of chronic disability, are poor measures of the value of our healthcare expenditures. Why? Continue reading U.S. Healthcare Costs & Benefits