Saturday, February 28, 2009

Wise Words about Medicare

I've taken the liberty of copying an editorial from today's New York Times. (Having been born in New York City I used to assume that all literate people read the Times!)

Medicare sets the overall direction for U.S. health care policy. I inserted numbers into the text to indicate points I comment on below:
Evidence and Health Care Reform
Medicare has proposed not to pay for so-called virtual colonoscopies because there is not enough evidence that they would benefit people aged 65 and older. That may be disappointing for older Americans who would prefer a virtual exam to a real one. (1) But those sort of judgments will be fundamental to any successful health care reform effort. Eliminating unproven procedures and reducing needless costs is necessary if the nation is to improve the quality and lower the cost of care over all.(2)

In a standard optical colonoscopy, a doctor inserts a long, flexible tube with a tiny camera at its tip into a patient’s rectum and colon. In a virtual colonoscopy, the doctor uses CT scans to produce images of the colon’s interior. If worrisome polyps are spotted, the patient then has to have them removed by a standard colonoscopy. Although a bowel-cleansing preparation is required in both kinds of colonoscopy, some patients are thought to prefer CT scans because they are less intrusive.

Some medical organizations have recommended virtual colonoscopies as an acceptable screening tool for colorectal cancer while others have found the evidence insufficient. Some insurers cover them; others do not. The CT scans detect larger polyps about as well as optical colonoscopies but are less effective at detecting smaller polyps.

Medicare’s concern is that older patients are more apt to have polyps than the average American. No studies have focused on how many Medicare patients who get virtual colonoscopies would then have to have polyps removed through a standard colonoscopy. If the number is large, the initial virtual colonoscopy will have been a waste of time and resources and will have subjected the patient to radiation that could have been avoided.

Medicare’s proposal is open for comments and the submission of further evidence before the proposal becomes final. Even if Medicare decides that virtual colonoscopies are clinically effective, it would then need to determine whether they are cost-effective compared with other screening options. They do not appear to be at current prices.(3)
(1) "Disappointing" is the key word here. Prudent management of the health system will entail disappointment. There's no way around it. Political leaders need to "inoculate" themselves against the backlash triggered by disappointment. In the U.S. we tend to believe that disappointment signals unfairness. It doesn't.

(2) Obviously "eliminating unproven procedures and reducing needless costs is necessary" for an affordable health care system. The most important thing about this sentence is its vagueness. Comparative clinical and cost effectiveness information won't manage the health system on its own. Some doctors and patients will follow it but lots will not. A viable Medicare system will constrain the autonomy of physician-patient dyads. In the past organized medicine has liked to claim "only the doctor can judge what is right for the individual patient." Two decades of research on unjustified clinical variation shows that this claim is false. Health care reformers will have to confront the hallowed U.S. sophism about "physician autonomy."

(3) This bland sentence has explosive potential. In its quiet way it is acknowledging the obvious. We need to ration. Every health system rations. The only question is whether it is done thoughtfully, as in the U.K., or cruelly, as in the U.S. The Republican sound bite machine is already waving the sword of the "R" word. Here's a quote from Republican House Leader John Boehner's website:
One of those [health care reform] proposals – dubbed “comparative effectiveness” – would lay the groundwork for a government takeover of American’s health care system by creating an organization to decide how to ration medical treatments. That’s right, congressional Democrats plan to “stimulate” the economy by reducing options for patients and doctors.
The health care reform process is sure to be nasty and brutish, but unlike Thomas Hobbes' prediction, it probably won't be short.

Wednesday, February 25, 2009

Obama, Kennedy, and Tough Health Care Choices

In his address last night President Obama spoke with force about the need for affordable, accessible, high quality health care for all Americans. It's hard to see how anyone can oppose those goals. But getting there will require tough choices that - notwithstanding his popularity - I don't think he has the political capital to carry out.

The goody goody proposals for reining in health care costs - more information technology, medical homes, and comparative effectiveness research - won't slow down the cost trend on their own. We'll need to confront our own ethic of unlimited choice, autonomy for every doctor-patient dyad, and condemnation of any effort to limit spending on costly marginal benefits as unethical rationing.

All developed economies have come to grips with these ethical challenges more robustly than we have. Their global budgets for health care don't allow the public and political leaders to pretend, as we have done for decades, that limiting health care costs is an ethical abomination.

We've created a climate of entitlement on the part of ourselves (the world of patients) and on the part of all the commercial enterprises that have been able to sell to a health system that refuses to get tough about purchasing.

Most physicians in their heart of hearts understand the situation and the need for change. But we need a strong public voice to tell us the truth and help us move forward.

I think the habits of entitlement and the commercial vested interests are too strong for President Obama to take on. Telling the truth won't be popular, and he has the most daunting agenda imaginable.

Since Medicare has to take the lead in insurance reform, we need voices from the Medicare constituency. And since setting limits on what we will pay for with collective (insurance) funds means forgoing beneficial interventions with small yield for the costs they entail, we need advocates who have looked illness and death in the eye.

That's where Senator Kennedy comes in. He just turned 77, and as the world knows, is being treated for brain cancer. He is uniquely positioned to tell us what we need to hear. It's not hard to know what has to be said - John Kitzhaber wrote much of the needed script in Oregon 20 years ago. We need leadership, not more research.

If Senator Kennedy's health allows him to take on this challenge he will leave a stronger country and a legacy to be proud of.

Monday, February 23, 2009

Should Zagat Review Physicians?

Wellpoint, which provides medical coverage to more than 35 million Americans, has teamed with Zagat, which is known for its restaurant ratings, to provide patient ratings of their doctors to Wellpoint members.

Doctors aren't happy. Here are comments from a recent New York Times article on the Wellpoint/Zagat collaboration:
“It is curious that they would go to a company that had no experience in health care to try to find out how good a doctor is,” said Dr. William Handelman, a kidney specialist in Torrington who is president of the Connecticut State Medical Society. “It certainly is very subjective.”

Dr. Angelo S. Carrabba, an obstetrician in Rocky Hill, Conn., complained that Anthem Blue Cross and Blue Shield, a WellPoint company, was “treating medical care provided by dedicated and caring physicians as if we were preparing a meal.”

Dr. Ronald C. Thurston, a psychiatrist in Ventura, Calif., questioned the validity of the Zagat feature. “Patients notoriously ignore their doctor’s advice to eat well and exercise,” he said. “Often they quit taking their pills when they’re feeling better. They usually don’t understand the technologies and skills needed for treatment.

Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, said he was skeptical about open forums evaluating doctors.

"There is no correlation between a doctor being an inept danger to the patient and his popularity," Professor Caplan said. Reviewing doctors is “a recipe for disaster," he said.
It's not surprising that doctors don't like the prospect of public ratings by their patients, especially by a company whose slogan is "Eat, Drink, Stay, Play." But I think it's a good idea.

Zagat has earned its good reputation in the consumer rating sector. My wife and I have used the restaurant guides for years. We understand that the guide represents a compilation of subjective reactions, not divine truth. Over time we've found that the subjective perspectives it presents are reasonable predictors of how we're likely to react. I'd be surprised if most of the folks reading this blog haven't sought out opinions about doctors from people they respect. Zagat ratings could contribute to that same process.

This is the rationale presented by Eric Fennel, WellPoint's Vice President of consumer innovation (see here):
"We've been doing patient satisfaction surveys for a long time. What we recognized was that we needed to create a vehicle that would engage people in this conversation and do more than just solicit their opinions. Most decision-making tools in the industry today are centered on providing clinical quality or cost information to members. When people have to make a decision they tend to turn, first and foremost, to friends and family for help and guidance and then look to other information that might be available."
In thinking about an innovation like the Wellpoint/Zagat collaboration we should assess risks and benefits as we do elsewhere in medicine. There is no doubt that, as Arthur Caplan says, "There is no correlation between a doctor being an inept danger to the patient and his popularity." But his conclusion -that reviewing doctors is “a recipe for disaster," doesn't follow. We assess whether a doctor is an "inept danger" by whatever process (does he wash his hands before examining his patients?) and outcome (do his patients recover from surgery well?) measures that are available to us. What gets called "technical quality" is the baseline criterion for making a referral. But the subjective factors that the Wellpoint/Zagat system is setting out to summarize can help patients choose among qualified physicians.

But in many areas of medicine "subjective" factors - including plain old likeability - contribute to the therapeutic potential of the doctor-patient interaction and should therefore be considered "technical" factors as well. And painful as it can be, receiving the kind of feedback the Zagat process is intended to provide can potentially help us become better "human technicians."

Friday, February 20, 2009

Riegel v Medtronic - a Clash Between Ethics and Law

A year ago today, on February 20, 2008, the Supreme Court decided Riegel v Medtronic by an 8-1 decision, with Judge Ginsburg as the sole dissenter. Riegel concluded that the Medical Device Amendments of 1976 meant that "no State 'may establish or continue...with respect to a device...any requirement' relating to safety or effectiveness that is different from, or in addition to, federal requirements."

The decision means that FDA approval of a device preempts the rights of individuals to sue for damages caused by the device and similarly preempts the rights of states to enact more stringent standards than required by the FDA.

Riegel may be good law (8 justices thought so), but it's bad ethics.

Today's New York Times reported that Representatives Henry Waxman, chairman of the House Energy and Commerce Committee, and Frank Pallone Jr., head of its health subcommittee, plan to introduce legislation that would nullify Riegel. A similar Senate bill, sponsored last year by Senators Kennedy and Leahy, is expected to be reintroduced in the next few months.

The core issue is the relative priority we give to competing values. Getting FDA approval for a device - especially at the highest (Tier III) level - is very demanding in time and cost. Device manufacturers argue that allowing post approval tort claims against them and allowing states to impose higher safety standards will impede bringing new devices to market. They're invoking the potential benefit of new devices as the key value.

Critics of Riegel give more weight to safety concerns. Here's what the Times article reports:
The lawmakers, as well as patient advocates and others, say the Supreme Court’s medical device decision has left patients legally powerless against what they criticize as spotty oversight of products by the F.D.A.

“Consumers face the worse of all possible worlds,” said David C. Vladeck, a professor at Georgetown University Law Center and a medical industry watchdog. “The F.D.A. has shown itself incapable of keeping dangerous products off the market, and now the Supreme Court has said patients can’t sue companies for redress.”
Providing benefit and avoiding harm are fundamental health care values. The question for ethical reflection is - when push comes to shove with regard to oversight of medical devices, which should prevail?

The answer comes from the adjoining article in this morning's Times, headlined "Guilty Pleas in Inquiry Into Stryker’s Marketing." The article reports that two former Stryker sales representatives have pleaded guilty to charges that they had promoted off-label use of the products even though they knew that such use had earlier caused problems in some patients. One claimed - all too plausibly - that Stryker's compensation system encouraged the fraudulent practices.

Even apart from criminal fraud we know that the FDA is not able to conduct adequate post marketing surveillance. Tort liability and the potential for states to set their own requirements are necessary for public safety. Sadly, the revelations of corrupt corporate practices have undermined trust in self regulation by device and pharmaceutical manufacturers.

Riegel v Medtronic tells us what the law says about medical devices. But Representatives Waxman and Pallone, and Senators Kennedy and Lahey understand that good ethics and sound public policy require a change in the law.

Tuesday, February 17, 2009

Shared Medical Appointments (2) - A Clinical and Ethical Innovation

In December I wrote about how Harvard Vanguard Medical Associates, the group practice I was part of for 32 years, is implementing shared medical visits. Today National Public Radio had a story about shared visits that is well worth listening to.

Gary Watson recently called the office of Dr. Charlie Tracy, his primary care physician. He wanted to get in to talk about his sleep apnea and some muscle pains. Mr. Watson reports "They said, 'Wait a minute, can you get here at two-o-clock this afternoon?' 'Why?' I said suspiciously. And they said, 'We're going to have one of these groups with Dr. Tracy.'"

In the NPR story we hear Dr. Tracy talking to Joanne, whose varicose veins are giving her more trouble. He looks at the veins in her calf and uses the opportunity as a "teachable moment" to discuss varicose veins with the group. Dr. Tracy does two group visits a week. He says he likes them because his patients don't feel so isolated by their illnesses in a group setting.

But he says there are limitations - "Sometimes you can't quite go into the depth that you'd like to. Some patients may be a little shy and not bring out the things they want to." But overall Tracy feels that what patients gain from the group outweighs what they might lose. "And they get to spend 90 minutes. Where else can you spend 90 minutes with your doctor? So I think for most patients it's as good and, many times, better."

But why am I writing about shared visits in a blog about ethics?

It's because I think the innovation is relevant to the question of how values change. I've felt for a long time that our national approach to health system ethics is too atomistic - focused almost exclusively on individuals with minimal attention to the needs of the wider population. I've advocated for a more communitarian ethic in writings and talks, but speeches and articles don't accomplish much, even when given by people with more eloquence than I can muster.

Shared visits let people - patients and physicians - kick the tires of a more communitarian approach. Gary Watson told NPR that even though he came to talk about his muscle pains and sleep apnea, he also learned about the shingles vaccine, how a few glasses of wine each night can raise blood pressure, and other health tips that made the ninety-minute visit a good use of his time. He says he'd come again. "I think there's a shared energy in the room...everyone seems to be open to receiving help as well as helping other people."

We all experience illness and we're all going to die. We should be thinking about health care, the resources we devote to health, and our approaches to healing, in terms of the needs of populations as well as the needs of individuals. Shared visits, which research shows to work well, provide one way to expand our moral horizons.

Friday, February 13, 2009

Adolescent Self-Determination, Cancer, and Ethics

Harvard Medical School's required course in "Medical Ethics and Professionalism" had its first seminar session yesterday. The topic was informed consent.

For part of the seminar we discussed the following real life situation:
In June 1994, Billy Best, 16 years old, was diagnosed with stage II Hodgkin's disease. With chemotherapy and low-dose radiation, 90-95% of such patients can be cured. Without treatment, death is likely. After two months of chemotherapy, he was reportedly experiencing minor side effects such as hair loss and fatigue. At this point he ran away from his home. In a note to his parents, he said that he didn't want any more treatment, the chemo was "poisoning his body" and that he was tired of having "no say" over his treatments.

He was missing for several weeks. His family made multiple television appeals. Finally he made phone contact with his parents from Texas, and agreed to come home only if he could refuse any further chemo. His parents readily agreed, and he returned home, with television coverage on the news. He and his family said that they would like to continue to see their doctors at the Dana Farber Cancer Center, but only under the conditions of no further chemotherapy. What should the oncologists do.?
The 13 first year students took the role of the oncologists while I played Billy. Although I gave them a hard time, and didn't yield at all to their efforts, I thought they did a superb job of trying to persuade me to accept chemotherapy by eliciting a rich sense of what I enjoyed most in life, letting me know about the bad prognosis without treatment, the likelihood of a positive response, and the fact that while the side effects felt terrible (not "minor" as described in the vignette, which obviously wasn't written by Billy), they would only last for a few months.

When Billy persisted in his refusal, explaining that he wanted "natural treatment," not "poison," and that he trusted God to make things turn out right, they asked to speak with his parents. I shifted into the role of Billy's father, and supported my son's position.

Given that their best efforts at rational persuasion had not changed "Billy's" mind, the discussion shifted to the question of whether the oncologists should turn to coercion, and ask the court to require treatment. The seminar was divided, much as society is. One group, including students with a libertarian bias, couldn't stand the idea of a 16 year old who loved being alive dying an avoidable death. This group would turn to the court. Others were impressed with Billy's thoughtfulness and the fact that his parents loved him, understood what the doctors were saying, but supported his choice. They took Billy's stand to reflect an informed consent that should be respected. This group proposed to follow Billy, hoping for the best, but intending to negotiate with him if the cancer progressed.

I had done a web search before the class to see if I could find more information about Billy Best's fate. To my surprise I found a website created by his parents. After much inquiry Billy had taken Essiac, an herbal potion. He and the family had made much use of prayer. The cancer had disappeared, and the last posting on the website (2007) shows the picture of a handsome, healthy-looking 29 year old.

Here's what the website says about Essiac:
Everyone interested in organic herbs has the right to know the truly wonderful history of Rene Caisse and her legendary ESSIAC ®. For 55 years, and with a large measure of success, Nurse Caisse used her herbal formula which she named ESSIAC ® to help thousands of people.

Dr. Frederick Banting, world famous Canadian, discoverer of INSULIN, winner NOBEL PRIZE 1923, concluded in the 1930’s that it was the positive benefits of taking ESSIAC ® which had helped to restore a woman to a healthy state.

It was Rene Caisse’s formula and the remarkable results she achieved with ESSIAC ® that stimulated 55,000 people - those she had helped, their families, their doctors, and friends - to sign a petition in 1938 requesting that Rene Caisse be permitted to continue, without fear of prosecution, her work with ESSIAC ®.

Rene Caisse diligently and closely protected her original botanical formula by not revealing it to the medical authorities and others in the scientific and business community. Before she would reveal her formula, she wanted official public recognition by governing bodies of the merits of ESSIAC ®. She also insisted on a guarantee that ESSIAC ® would continue to be available to people, and not disappear into secluded laboratory testing on animals, which had happened to other non-toxic drug free materials.
The students and I discussed what to make of Billy Best's story. Being schooled in the scientific method and educated not to base conclusions on "anecdotes," none of us were inclined to become believers in Essiac. If the substance is studied rigorously in the future and found to have anti-cancer efficacy we will recognize the error of our ways. But we all took a lesson about prognostic uncertainty and the need for humility. I felt that wasn't a bad end point for our first seminar.

Wednesday, February 11, 2009

Curing Medical Loneliness

An article in yesterday's Washington Post - "Sharing the Pain: Rare Disease Puts an American University Economist in Touch With Fellow Patients Around the World" - caught my attention.

In 2005 Arturo Porzecanski, an accomplished economist, developed a life threatening and often fatal disease called "systemic capillary leak syndrome." I'd never heard of this rare condition, in which there are sudden episodes of leakage from tiny blood vessels and a precipitous drop in blood pressure. Porzecanski was left with muscle loss after his first episode and was told that the next one might kill him. He "was very depressed and felt increasingly alone" until he found RareShare, a website whose purpose is to foster contact between people who, like Porzecanski, have rare diseases.

In my clinical practice I often referred people with significant psychiatric ailments to organizations like NAMI (National Alliance on Mentally Ill) or the Depression and Bipolar Support Alliance for opportunities to meet and hear from others with similar conditions. For many people organizations like these provided emotional support and sometimes "tips" on coping with symptoms like hearing voices or depressive hopelessness.

But for rare conditions like what Porzecanski has - the Mayo Clinic has seen only 28 cases in 25 years - the isolation can be debilitating. Despite a supportive family he felt very alone. Here's what Porzecanski says about the new website:
"RareShare put me in touch with other patients. It gave me great pleasure to put down everything I knew: all the critical articles, the world's experts, information about custom shoes. For me there was just a lot of support in knowing I was not alone."
I browsed on the website. It's obviously young. Many of the "communities" have just one or two members, and not all have generated real discussions. But some, like the systemic capillary leak syndrome "community" that Porzecanski started, have the beginnings of a rich and meaningful exchange. Some, not surprisingly, have energetic reports of what to me sound like quack ideas. But that's part of human life and not peculiar to the web.

Insofar as the web and portals like RareShare facilitate creation of virtual communities in which people can "meet" others with the same condition to exchange ideas and mutual support it is all to the good. It will be important for doctors and nurses to learn about these new resources and how to counsel patients about using them.

But I fear the risk of corruption of these grassroots enterprises by commercial interests. This has already happened enough to elicit a new term - "astroturf" - for pseudo grassroots organizations driven by corporate support such as pharmaceutical companies that want to market high cost drugs for the condition. (See here for an example of astroturf I wrote about in 2007.) I hope that RareShare's business plan does not involve selling the soul of person-to-person exchange to the highest corporate bidders. If it's able to resist corrupting temptations it could make a meaningful contribution to human well being!

Tuesday, February 10, 2009

Drug Trials in India - a Video Interview with Amar Jesani

Anyone interested in the ethics of clinical trials in developing countries should look at this five minute video of an interview with Amar Jesani, a leading human rights advocate in India.

Dr. Jesani, who I had the privilege of meeting with at the Center for Studies in Ethics and Rights in Mumbai during my recent trip to India, reports the prediction that in ten years one third of all clinical trials will be done in India. The primary reason is cost reduction - trials are 50% - 75% cheaper to do in India than in the U.S. And India's huge population means that there are enough patients with the condition being studied to conduct most trials.

According to Jesani it is easier to carry out trials in India because although there are laws that ostensibly protect patients, regulation is very lax. Poor patients are desperate for care and are typically subservient to their physicians. Government inspection and ethics committee oversight is week, and the regulatory process is subject to corruption. The picture he sketches is not pretty.

Jesani explains that he and his colleagues are fighting for three things. First, clinical trials done in developing countries should be relevant to their needs. Second, in the course of the trials there should be no human rights violations. Finally, if the trial is successful the drug should be available in the developing country at an affordable price.

The video is thoughtful and constructive. The comments it received are not. Here's the most printable one: "I have been conducting clinical trials around the world for 18 years. This video is a scam this doctor is a liar...This guy is probably trying to scam a few million from the drug companies in an extortion con."

In the last few years in the U.S. we've seen a rising crescendo of criticism of the ways the pharmaceutical industry has corrupted science and clinical judgment. The ethics of international drug trials will come next in this advocacy process. If the issues are new to you, have a look at the video.

Monday, February 9, 2009

The Academy of Allergy, Asthma and Immunology Disgraces Itself

The American Academy of Allergy, Asthma and Immunology (AAAAI) has cancelled plans to hold its 2015 meeting in Boston because of a new Massachusetts law imposing tighter regulations on medical industry marketing.

Apparently the sticking point was the law's requirement that CME activities must meet standards set by the Accreditation Council for Continuing Medical Education (ACCME) or an equivalent body. This requirement would prevent the AAAAI from offering CME credits for poster and abstract sessions sponsored by industry.

Anyone who has attended a CME conference knows that industry poster sessions are marketing activities, not continuing medical education. This doesn't mean that poster sessions should not occur, but that they should be recognized for what they are. Marketing is a legitimate activity. So is CME. But they're not the same.

I hope the AAAAI experiences a backlash from its membership. Given the crescendo of publicity about the corruption of CME and, alas, research, by industry, backlash is likely.

Shame on the Academy!

[See here and here for further information about the AAAAI cancellation.]

Saturday, February 7, 2009

IBM and UnitedHealth Experiment with Medical Homes

Lately I've been dabbling in realism in this blog. Basing our health insurance system on employers is a cockeyed idea that emerged during the World War II wage freeze. But it's the system we have. Happily, employers are getting mad about how much insuring their employees costs and how mediocre the high priced care is, and they're taking some promising steps.

An article in this morning's New York Times reports on a medical home program in Arizona between IBM, which has 11,000 employees there, and UnitedHealth, its insurer. What's important is not the idea, which is mainstream common sense, but the fact that two huge corporations are running with it.

"What we buy is garbage." That's how Dr. Paul Grundy, IBM's director of health care transformation, describes the care health insurance typically provides. IBM catalyzed formation of the Patient Centered Primary Care Collaborative, for which Grundy is chair. The organization advocates for a coordinated, primary care-centered health system based on these sensible principles:
Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home:

* Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
* Evidence-based medicine and clinical decision-support tools guide decision making
* Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
* Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
* Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
* Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
* Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
Of the Arizona program Grundy says “We’re not doing this because we expect to see huge savings. The medical home is more about whether patients have access to care at the right time and whether that care is appropriate. I think it’s the right thing to do.”

The medical home concept isn't new. The American Academy of Pediatrics introduced it in 1967. What's new is the degree to which businesses are endorsing it. Having a good idea is a starting point. But when IBM talks, people listen!

[For previous postings on how employers can contribute to a more rational and ethical health care system, see here, here and here.]

Tuesday, February 3, 2009

Complementary Medicine

A conversation with a colleague today got me thinking about how mainstream U.S. medicine ("western medicine," "allopathic medicine," "evidence-based medicine") relates to the wide range of complementary approaches.

Here's my reconstruction of what my colleague said:
"I had bad gastric reflux symptoms for a year. I tried changing my diet but that didn't do the job. My primary care doctor suggested Prilosec, but it didn't help. Then he suggested Prevacid. It cost me $50/month [this was the copayment at the pharmacy - when I checked on line today the lowest price for 30 30 mgm tablets was $189!] and I just didn't feel right on it. My joints hurt and I felt funny. He referred me to a GI specialist. She did an endoscopy. It showed some little growths in the stomach apparently caused by Prevacid. She suggested that I continue taking the medicine anyway.

But I'd had it with Prevacid, so I stopped it. I decided to look into alternative ("natural") approaches. Someone suggested that I try Probiotics. [Here's what the National Center for Complementary and Alternative Medicine says about Probiotics: "Probiotics are live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gut. They are also called "friendly bacteria" or "good bacteria." Probiotics are available to consumers mainly in the form of dietary supplements and foods."]

An Indian man at Whole Foods suggested what to try. It worked well. My reflux symptoms went away and the side effects of Prevacid were gone. I felt well.

I went back to the GI doctor for a follow up appointment. First I saw the nurse. I told her what I'd done. She said 'Lots of patients tell me that approach works for them.' But then the doctor came in and she stopped talking, as if she was saying something she wasn't supposed to say.

When I told the GI doctor about the Probiotics she said 'I've heard that it has helped some people, but we can only recommend what we know works.'"
I don't think this is an unusual vignette. Most physicians I know are not comfortable considering "alternative" approaches. I have no expertise in that area, but here's what I would have had the GI specialist say:
"I've heard the same thing from some other patients. From a scientific perspective we don't know whether this approach really works. But if you definitely feel you are doing better, I suggest that you continue what you're doing and monitor how you are. I also suggest that you go onto the web and see what is being said about Probiotics. Keep in mind that you can't believe everything you read. If the symptoms come back I'm happy to see you again. And if you're doing well - and I hope that's what will be happening - please give some follow up to your primary care doctor, just to make sure he knows how you are and what you've done for the symptoms."
"Evidence-based medicine" is a noble concept, but it's too much of a buzz word now - almost like a point of religious faith. Sometimes our evidence about what works is powerful, but often it's so-so at best. We should try to guide ourselves in accord with established facts, but we need to be more humble about the limits of our knowledge and more practical than my colleague's GI consultant was.

Since my first reading of Plato I've admired Socrates for his insistence that wisdom resides in acknowledging the depth of our ignorance. From my brief literature search today it looks as if evidence about the effectiveness of Probiotics for gastric reflux is somewhere between skimpy and nil. But my colleague's many months of experience with Prilosec and then Prevacid had produced no benefit, no matter what the "evidence" about statistical effectiveness might be.

A clinician schooled by Socrates would be able to acknowledge (a) the evidence we have favors medications like Prilosec and Prevacid, but (b) "evidence" isn't divine truth, and (c) thus far my colleague seemed to be doing decidedly better following a non-evidence-based approach so that (d) wisdom suggests continuing that approach and monitoring clinical status. The key evidence is how the individual human being is actually doing.