By Dov Michaeli MD, Ph.D

Every Sunday morning we have a family ritual: 8-9 in the morning it’s “Meet the Press”, 9-9:30—the Chris Matthews Show. And while the TV is blaring and we OD on politics, we walk on the treadmill or step on the elliptical, do abdominals and pushups, do Yoga and lift weights—in short: we indulge our political and fitness addictions simultaneously, and feel self-righteous and quite superior to the flabby unwashed masses.

I love to watch Chris at his best: benignly opinionated, urging his guests to express their opinion on a political subject before pronouncing the Matthews ‘truth’ (“Tell me something I don’t know… here is what I think”), full of lively energy; the man is manifestly enjoying exposing hypocrisy, mendacity, stupidity and other ills of our political leading lights.

So guess how surprised I was when I found out that Chris Matthews makes stupid mistakes, like any one of us. As I sorted through today’s mail my eyes fell on the cover of the latest issue of Diabetes Forecast. There he is on the cover, smiling his heart-melting Irish smile, over the title: “Chris Matthews: the Hardball host goes head-to-head with type 2”. I guess for the readership of this magazine there is only one sort of “type 2”— diabetes. Chris was interviewed by Dan Gilgoff, the politics editor of Beliefnet.com and author of The Jesus Machine: How James Dobson, Focus on the Family, and Evangelical America are Winning the Culture War. (I can’t resist a digression here. Dan, don’t fret: Dobson, Focus on the Family, and Evangelical America are losing the cultural war!).

The interview was an eye-opener for me. I have to admit, I used to attribute much of the American people’s lack of sophistication in health matters to poor education. No more; here is a highly educated individual, possessing an uncanny capacity to ferret out ignorance, stupidity, and dishonesty who betrays an incredible degree of ignorance when it comes to his own health.

Here are some excerpts from the interview, along with some gratutitous comments.

Q. You knew for years that you had diabetes but did very little about it.

A. … I had malaria after coming back from a trip to South Africa in 2001, but what I kept [hearing about] from my doctor was my high blood sugar levels. And I said, “What does that have to do with anything?”

Comment: Chris, with your sharp ear to nuance and encrypted messages—what did you think your doctor was trying to tell you? And you, doctor, were you too pressed for time to press your point home? By the way, going to South Africa without taking the Malaria pills? Did you think you were beyond the reach of lowly creatures such as mosquitoes?

Q. But you more or less ignored your diabetes until even more recently, right?

A… I also wasn’t doing any kind of dieting. I was aware of a general need to skip some things. The toughest habit is going to an airport in the morning when you haven’t had breakfast and seeing the pastries there. Hunger is the best chef—you see a couple pastries and have that and a cup of coffee for breakfast. There was a time when I’d have a hamburger and French fries for lunch with a beer or white wine, and I’d have cheesecake for dessert. It was pretty outrageous.

Comment: I agree. Many a time did I find myself struggling to walk past the Peet’s and Starbuck’s Coffee stands at the SF airport, without succumbing to the temptation of the pastries. But where was your doctor? How come you weren’t warned about pastries, hamburgers, French fries, beer or white wine for lunch? This is inexcusable.

Q. Did you consider reforming your diet after learning about your high blood sugar levels?

A…. I didn’t say, “Wait a minute, this is something I can reasonably deal with.” I didn’t understand the importance of it or the doability of it—that I could solve this problem, that it would be over, and I would be just like everybody else….

Comment: That he didn’t understand the importance of it is in part his doctor’s fault, and in part Matthews’ own dismissive attitude when confronted with inconvenient facts.

Q. You stayed in the hospital a few days. How scary was it?

A. When you have three doses of morphine and it still hurts, you begin to worry.

Comment: And I am sure you went back to your TV show, blasting any and all comers for their lack of clear solutions to our health care problem. Chris, it is people like you who are part of the problem.

Q. You’ve certainly lost a good bit of weight in the past year.

A. On my scale at home I’ve gone from around 235 to about 205, and I think I can lose some more if I do a little more exercise. I really haven’t done any exercise to lose all this weight, just changing what I eat.

Comment: Chris, I watch you every Sunday on TV. You need to lose a minimum of 20 more lbs. You may rid yourself of the daily insulin injections, and as a bonus, you’ll wow the beautiful female political commentators on your show if you lost 40 lbs, and exercised!

Q. Why your aversion to exercise?

A. Don’t have any time. When am I going to do it?

Comment: What a lame excuse. There are people who run multi-billion dollar enterprises who find time to exercise. You make time, Chris. Get up one hour before you normally do, and just do it. It is going to grow on you, it will energize you to go after the bad guys, and you’ll feel sick on days that you skip—I guarantee it.

Q. As a public figure, do you feel obligated to send a message about diabetes?

A. What people ought to be told about diabetes is that if they have it in the family or sense that they’re on the road to it, they should go to their doctor and ask him what he thinks and actually listen to the doctor like they would use [their] financial advisor.

Maybe it’s an Irish thing—we like to think we can talk our way out of things or that we can avoid them. But I’ve come to respect doctors a whole lot through this whole thing because they know what they’re talking about and they’re telling you to do something for your own good.

Comment: You are right, Chris; people ought to listen, even more than to their financial advisor. It is a matter of their health and life—pretty existential stuff.

But you are wrong about it being an “Irish thing”. I have had Russian patients come in with a list of medications and treatments they had decided they needed, and all attempts at telling them otherwise were a waste of time. My own father would go to the doctor only to tear up the prescriptions he was given and treat himself with his grandmother’s nostrums. And my Rabbi told me that when your Celtic forefathers had no idea that the emerald island even existed, the Jews of Ireland already suffered from diabetes. And why did they have diabetes? Because they didn’t listen to their (Jewish) doctors.

See you next Sunday on TV.

Dov Michaeli MD, Ph.D is in the biotech industry

by Brian Klepper, PhD

There are people who call for market solutions as the answer to every societal problem, but who then work to restrict the information that markets (and societies) must have to function effectively. Often, the truth is that these supposed market advocates need secrecy and opacity to protect their current advantages. If markets were to work as they claim they want, their actual behaviors (or pricing, or performance) would become known, and their positions compromised.

Which brings us to the new, interesting development in the case of Consumers’ Checkbook v CMS. You may remember that Consumers’ Checkbook (CC) is a consumer advocacy organization that sued CMS for the Medicare physician data in 4 states and DC. Seemingly arguing against their previous position, the Bush Administration – which actually has a good record for promoting health care pricing/performance transparency – took the opposite stance in this case, arguing instead that physicians have a right to privacy. (It is tempting to suggest that the AMA’s fingerprints must be all over this, but I don’t know that for sure.)

In any case, much to the surprise of me and, I’m sure, a lot of other people, on August 22nd, the court held with CC and ordered CMS to release the data by September 21st or appeal the decision. CC promptly promised to provide public access to the data, and sued again, this time for the Medicare physician data from the rest of the country.   

On October 19ths, CMS appealed the ruling. This means the Administration will fight to keep physician data out of the public’s hands.

As I’ve said before, in the short term the symbolic importance of this battle cannot be overestimated. Currently, there are few, if any, freely available, robust sources of claims data. Health plans and clearinghouses have the largest data sources, but these are typically proprietary.

If a startup company wants to identify the best performing physicians in any market – the ones who, in a given specialty, consistently obtain the best outcomes at the lowest costs – there is no easy way to independently do that.

Or let’s say you have a family member with a complicated condition or who needs a particular procedure. There is no direct way for you to objectively determine which community physician has the best track record with that condition or procedure. (You CAN get information on which car has the best repair record, which house repair contractor gets the best reviews, and which pizza restaurant delivers the fastest.)

The good news is that the Administration’s position is weak, at best, and won’t last long, even if they win this round. Hospital data is already publicly available and states are now actively publicly reporting key measurements of hospital quality and safety. Why should physicians have a special status that keeps their track records secret from the patients who depend on them? How can this Administration, which argues incessantly for market-based solutions, suppose that the health care marketplace can resolve the crisis when, as the great economist Adam Smith would have pointed out, there is no information to drive the decision-making that healthy markets require.

It is ironic that we’re even still having this discussion. In the first years of the 20th century, the famous surgeon Ernest Codman MD began to campaign for “the end-result system of hospital standardization.” He said,

Hospitals [and surgeons], if they wish to be sure of improvement...must analyze their results, to find their strong and weak points, [and] must compare their results with those of [their peers]...[They should] make this information publicly known so that the future patients might make informed decisions.

In the end, it won’t matter what this Administration does. There is now widespread acknowledgment that much of the health care crisis can be traced to an inability to see what is going on behind the curtain. A tidal wave of sentiment is building in the marketplace, with calls for making the information available, so that decision-makers of all types can make responsible, informed decisions.

It is difficult to imagine that this stonewalling can last much longer. If transparency doesn’t occur through policy change, it will surely happen in the marketplace through vendors with the heft and resources to see it through. If the recent Health 2.0 conference in San Francisco made any point emphatically, it was that a slew of companies are focused on infusing health care with unprecedented levels of transparency and decision-support.

The transition away from an opaque market to one that makes relative pricing and performance known and that rewards the good providers is the real health care reform we’re all looking for. Yes, we need to find a way to re-enfranchise everyone into the system. But that will be much easier if there is reason to believe that we can get excessive care and cost under control.

And to that end, Consumers’ Checkbook v CMS is a sideshow, not a pivotal decision. On this issue, the Bush Administration and whoever is urging them on are anachronisms that will soon be swept away with the buggy whip and White-Out. The real change agent here is technology and the long-overdue realization by purchasers of all kinds that, when markets are opaque, value becomes secondary and many vendors will act most assertively in their own interests first.

Brian Klepper 

How do you live a long life? Take a two-mile walk every morning before breakfast.

Harry Truman
33rd US President, who lived to 88

DAWN, n. The time when men of reason go to bed. Certain old men prefer to rise at about that time, taking a cold bath and a long walk with an empty stomach, and otherwise mortifying the flesh. They then point with pride to these practices as the cause of their sturdy health and ripe years, the truth being that they are hearty and old, not because of their habits, but in spite of them. The reason we find only robust persons doing this thing is that it has killed all the others who have tried it.

Ambrose Bierce, The Devil's Dictionary 

 

I started taking long walks with my close friend Bob thirty-five years ago when we were students in Holland. We would walk and discuss the things that young people ponder, passing time in the brisk beautiful outdoor landscape of Northern Europe. We always maintained a quick pace, but never minded the effort, because the activity was filled with ideas and always-inviting scenery.

When I returned home, walking was a habit that stuck with me. When Bob and I lived in the same town, we'd get together regularly to walk the dogs. On my own, I found that I could go out for a stroll and think, chewing on whatever I was working on and, getting a little distance from it, find perspective. Elaine and I still walk, constantly, and that's where we get some of our best talking in. Walking has been respite from the rush, a place to hash out conflicts or work out plans, a way to meditate and regain balance.

When I left my post at the University of Florida about 20 years ago and returned home, I traded a landlocked town for the coast. As quickly as I could, I resettled within a few blocks of the beach in a small community on an island off Jacksonville, in Northeast Florida. Then, as now, I was literally within a five minute walk of a 300 foot wide, hard-packed, sugary white sand beach on the Atlantic, stretching for miles both north and south. In addition to the spectacular, always changing beauty of a vibrant seascape - birds, dolphins, turtle nests, fish and other sealife; the boats and ships just offshore; the surf rolling in and lapping the beach - it was perfect terrain for a habitual walker.

Even so, as easily accessible as it is, and though I know lots of people long for just this sort of environment, there have been periods when I lost my discipline, when I took the opportunity for granted and somehow just didn't get around to it.

Then came the moment 5 years ago when I unexpectedly had open heart surgery, a 5 vessel CABG, the result of lousy genes and the gradual relentless buildup of plaque choking off my blood vessels. During the procedure they collapsed and then re-inflated my lungs, and I knew it would take work to ameliorate my shortness of breath. I started walking again immediately, through the halls, on the second day in the hospital following my surgery, and by the time I left 3 days later I was up to walking more than a mile a day.

I continued when I returned home and worked through recovery, and though increasing my distance went slowly, I kept at it. During a follow-up with my surgeon, he commented, "The best thing you can become is a walking fool. It's low impact, steady and its good for you in all kinds of ways, especially with what you're up against."

And then, again, time passed and I got comfortable and distracted. I skipped my walks and then they trickled away, until I was just walking weekends again. I told myself that I was really in OK shape, but the truth was that I put on weight and that I had slipped into a malaise.

Recently, I had a discussion with a good friend, a preventive cardiologist, who gave it to me straight. I had shared the numbers from my last blood panel. "Look," he said, "you're not taking this seriously. Unless you get your LDLs (the bad cholesterol) down below 60,  you're going to continue laying down plaque, and the risk increases. If you're interested in doing what you can do, you need to get religion on this. Get lean. Eat carefully and ramp up your exercise."

And so I have.

This isn't just theory. Below is a picture from the REVERSAL Trial, led by Steven Nissen MD, chief of Cardiology at Cleveland Clinic. It clearly shows the before and after effects of managing LDL to below 60. After 18 months of the reduced LDLs, there's been a significant opening of the vessel. This is what I'm shooting for.

So we've cut out most breads and sweets. Cookies are out. Our diet is mostly fruits, veggies and fish. Once you get your head around it, it makes sense and you gradually lose the longing for the comfort foods: a milk shake, macaroni and cheese, or a fried fish sandwich.

And then there's the walking. It's a flat 3 miles, 50 minutes door-to-door, down to the lifeguard station on the beach and back, walking fast. Right now, in the NE Florida swelter, I'm soaked through when I return. I do this twice a day. On my suburban beach, around 6AM, there are 200 people out there walking before work. After work, you see  a lot of them again.

 

 An embarrassing quantity of pounds has melted off. I'm becoming leaner and stronger than I've been in years. The next blood panel will tell. When I'm tempted by some forbidden food, I think of 60 and my will to shrink the plaque that's strangling my vessels.

And I walk.

by Pat Salber, MD

The cabbie who drove me from the airport to the hotel on my last business trip probably weighed 400 pounds.  We made small talk during the trip.  He told me he was hoping to leave Nevada soon and move to Oregon.  But, he said, it was tough getting the time and resources to make the move.

He works 12 hours days, six days a week.  The cab company deducts chunks of his pay  for their share of his revenues and to cover his health insurance premium and a tax on his tips.  His take home pay is $500 every two week pay period.

As we started talking about his health insurance, the conversation naturally drifted to health.  He is prediabetic, he told me, and his brother is a type 2 diabetic who has already had some toes amputated.  He knows he is facing the same future if he doesn't lose weight, but how can he do it?

When you drive a cab 12 hours a day, you often eat on the run.  That means fast food, high fat, and lots of calories.  Also, how do you fit in exercise?  Should he try to walk before the 12 hour shift or, perhaps, go out in the middle of the night when his shift is over? 

I found myself wondering what I would do if I were his doctor.  Of course, I would recommend he lose weight, alot of it.  And, I would tell him to get moderate to vigorous exercise 30 to 60 minutes a day.  I would prescribe any needed medications.  And, I would tell him to join WeightWatchers, or better yet an on-line weight loss support program, like PEERtrainer (www.peertrainer.com).

Chances are, in my 15 minute office visit, I wouldn't have learned about the challenges presented by his daily schedule.  I wouldn't understand that my recommendations were unlikely to be followed -- not because he wouldn't, but rather because he couldn't.

If something doesn't change, his prediabetes will most likely become diabetes.  He will probably have a heart attack or stroke or maybe, like his brother, he will end up with toes or feet amputated -- all potentially preventable if he could change his lifestyle.

At the end of the ride, all I could think of to say was that he needed to get a new job -- one that is less stressful and would allow him to exercise and eat better.  But I knew this too would be a daunting task given the long hours he already works and the meagerness of his financial resources.

I keep mulling over his story and wondering, how could you help this man?  I haven't come up with an answer.  Can you?

This is an oldie, but goodie, first published on TDWI September 15, 2006

By William Bestermann MD

 

Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions.

Many professionals in positions of leadership today were educated in the 60s, opposed the Vietnam War, and viewed military intelligence as an oxymoron. But my oldest son, a West Point graduate, has taught me lessons that have changed my life and are relevant to the major conundrum facing medical practice today.

West Point places a primary stress on technical adaptation.  These young cadets are taught “Tactics Lag Technology.”  That is to say if the officer applies tactics appropriate to the last war in the face of more deadly weaponry in the current war, he will likely be responsible for the deaths of hundreds if not thousands of his personal friends, team mates, and countrymen.  Military officers, in their movement upward in rank and responsibility, learn of our own new technical capabilities, those of potential enemies, and how to integrate these into best military practices to minimize casualties while increasing the likelihood of success of the mission.  This is a central focus in military culture.

First, a bit of military history

These cultural attributes of the modern American military officer did not just drop out of the sky.  West Point cadets study the American Civil War in some detail.  That conflict saw the beginning of dramatic technical change including railroads, rifles in large number, and trenches that transformed warfare forever.  Prior to the War Between the States, for thousands of years, generals managed the attacking force in the same way.  The defenders would line up over a broad front, in ranks perhaps two or three deep, over a couple of miles depending on the size of the force. The attacking force would assemble in front of them in full uniform with color guards and regimental bands playing marching music.  Then the attackers would march to within effective range of their weapons.  As the Civil War began, most units were armed with muskets and the effective range was 40 yards.   So the Union and Confederate units would march to within 40 yards, fire one volley or perhaps several followed by a bayonet charge.  The carnage was not terrible and the loser was the one who lost his nerve and abandoned the field.  

As the war progressed, both sides replaced muskets with rifles and the defenders dug trenches.  As the Confederates prepared for Pickett’s charge at Gettysburg, the Union troops were behind a stone wall defense and armed with rifles.  Nearly a mile of open field lay between the opposing forces.  The Southern Commander Robert E Lee had ordered the charge, but Corps Commander Longstreet objected, simply knowing by observing the situation that the mission was impossible.  General Lee ordered him to charge the Union force in spite of the objection and Pickett’s Division was cut to pieces in a matter of minutes.

The following spring, US Grant had assumed command of all Union armies.  He was determined to end the war by capturing Richmond and crossed the Rapahannock River to begin what became the Overland Campaign.  In battle after battle, the Union forces charged entrenched confederates, with the same resulting horror the Confederates suffered at Gettysburg.  General Grant suffered 60,000 casualties in the month of May 1864 alone.  The puzzle of the rifle and the trench never was solved in the Civil War.

Amazingly, when WWI started 50 years later, tactics had still changed very little, though the technology of war had changed dramatically.  The forces involved had tanks, airplanes, machine guns, repeating rifles, mortars, breech loading artillery, trenches, and barbed wire at their disposal.  The method of attack had not changed.  The frontal assault was still the order of the day.  The British suffered 60,000 casualties on the first day of the Somme offensive.  The generals still did not get the message and over the new few months 500,000 promising young men were shot down in that single campaign.  WWI ended and the puzzle of the repeating rifle, trench and machine gun was still not solved.

The wrath of the status quo

The terrible carnage of WWI broke the spirit of Europe and there are still residual cultural effects on that continent.  In the aftermath, the promising young American officers Dwight Eisenhower and George Patton wrote infantry journal articles describing a new kind of attack that would later be called “blitzkrieg” or lightning war.  In this assault, all of the heavy weapons of the attacking force would be combined in units actually making the assault.  All of the tanks, artillery, bombers, machine guns, mortars and mechanized infantry would be thrown at the weakest point in the enemy line. They would break through, and turn left and right to “roll up” the force in the trench.  History has shown this to be a brilliant disruptive innovation in warfare and frontal assaults no longer occur.

How did the senior army leadership respond?  The Chief of Infantry called Eisenhower in and told him that his articles did not represent sound infantry doctrine and that if he wrote any more articles of that nature he would be court-martialed.  Billy Mitchell actually was court-martialed for advocating similar valid innovative disruptions in the army air corps.  Thank goodness the innovations advocated by Eisenhower, Patton, and Mitchell were adopted and played a critical role in WWII.

The change from frontal attacks to the attack of supreme violence aimed at a point is a very dramatic example of paradigm change.  The whole dynamic of combat changed from a defense that could not be overcome to an attack that could not be resisted.  The officers directing the blitzkrieg assault were not more diligent, more industrious, smarter, brighter or more dedicated than their predecessors.  No, they were not superior in any way-they had simply used a new system, a new application that was more effective.

So what does all of this have to do with medicine?  

You might think “How could these people be so blind? We would never do such a thing.”

Think again!  The science around medical practice in the treatment of atherosclerotic vascular disease has utterly changed.  The evidence that demands a change in paradigm has become irrefutable.  The technology of vascular medicine has progressed at a pace fully equal to that seen in the military.  The old attack on vascular lesions in stable patients aimed at fixed narrowings – bypasses and stents – are as thoroughly discredited as frontal assaults in the face of machine fire. (More on this in another post.)

The Institute of Medicine is the medical arm of the National Academy of Sciences.  The IOM membership is composed of 1,400 of the best minds in medicine.  In its 2001 report, “Crossing the Quality Chasm,” the IOM summarized what was needed to treat chronic conditions:

“The current systems cannot do the job. Trying harder will not work.  Changing systems of care will.”

This document is the medical equivalent of the infantry journal articles written by Patton and Eisenhower.  It is a call to action and change, yet little in practice has changed since it was published in 2001.  Why?  The Chief of Infantry is alive and well.  Paradigm change has dramatic consequences and, for the leaders of the old order, the changes are negative.

The consequences of the utter failure of leadership in this case are exactly the same as a frontal assault: thousands of dead and disabled as a monument to our inaction.  Heart attack and stroke accounted for roughly 800,000 deaths in 2003. Many of these deaths were premature and avoidable. The bodies may not lie in heaps before a trench-line, but they mean the same thing: a failure to bring the full benefit of new technology to those we have promised to protect. 

There is a very real price to be paid for our failure to translate our new scientific knowledge about vascular disease into practice.  The Steno II trial compared optimal medical care (that is, drug therapy) in type 2 diabetes to usual care, and reduced the number of vascular events by half.  Only a small percentage of the study's patients had to be treated more aggressively to prevent a heart attack or a stroke.

The type 2 diabetic has a lifetime risk of dying from a vascular event of 65-80%.   Each risk factor - glucose, pressure, and cholesterol - treated to goal using the right medication reduces the risk of a vascular event by half.  Only 7% of type 2 diabetics have all three risk factors simultaneously to goal. 

Our failure to provide more aggressive risk factor management in these patients obviously is very damaging to their health.  The economic cost is equally painful.  Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions. In stable angina patients, optimal medical therapy was just as good in preventing a heart attack in a stable angina patient as optimal medical therapy plus a stent—for one third of the cost.

If current trends are any indication, medicine, the insurance industry and government will be slow to lead on transformation.  Patients and businesses that pay the bills must demand better or continue to receive medical care that is not what it could be.

Dr. Bestermann is medical director of the Vascular Medicine Center at the Holston Medical Group in Kingsport, Tennessee.

By Brian Klepper

I generally make a point in my professional writing not to talk about myself, but today I make an exception.

It was 5 years ago today, July 5, 2002, 3 weeks before my 50th birthday, that I had open-heart surgery, where the blocked arteries of my heart were replaced. In medical shorthand, the procedure is called a CABGx5, which means a 5-vessel Cardio-Arterial Bypass Graft. In other words, they used pieces of vein, in my case from my leg, to reroute 5 vessels that carry the blood from my heart to feed the rest of my body. If you think about it, it’s a straightforward piece of mechanics, but of course it really is a modern miracle, the product of great advances in knowledge, skill and technology.

It surprises people when I tell them that having open heart was one of the most positive experiences of my life. But it’s true. How many of us go through an experience that takes us to the edge of death, and then, within a couple of weeks, has us back and engaged in life, physically and emotionally revitalized?

If I had lived 100 years ago, I’d almost certainly have died before my 50th birthday. Only because I had the great fortune to have resources, to live in a wealthy nation, and to live in this era, am I alive to really enjoy and be engaged in life over the last five years. That pleasure was, of course, heightened immeasurably by the just-glad-to-be-here exuberance that I still feel every day.

On this day, I think of the many people I owe great debts to:

• My physicians, Drs. Glock, Schrank and Koster, whose great skill and grave humor pulled me through.
• The Baptist Health System nursing staff, who cheerfully and capably goaded and guided me through my inpatient stay, rehab and home care.
• My great pal Steve Blumberg, who did much more than I was aware of to make sure all would run smoothly, which it did.
• My good friend George Lundberg MD, who called and calmed me with the facts when he heard about what was in store.
• My dear childhood friend Fannie Newman, gone now, who by serendipity called me the night before my surgery, and who, by the example of her own much greater courage, inspired me to face my fear directly and to understand that I could play an active role in my own recovery.
• Brooks and Helen Brown, who sat with Elaine during the entire surgery and provided unwavering support.
• Randy Kammer and my friends at Blue Cross and Blue Shield of Florida, who immediately jumped into the fray and expedited my care.
• My many friends, who came out of the woodwork and made me remember that life is about touching souls.
• And most of all, to my wife Elaine, who really brought me through, and whose presence then and now is the light of my life.
  

Here’s what I wrote in the weeks after my surgery, as I was re-emerging. I was so engrossed in the experience, I recorded it so I would never forget.

Thanks for indulging me on this day.

Brian


August 25, 2002

Recently I received a big surprise, open-heart surgery. For several weeks beforehand, my chest hurt and I was short of breath whenever I mowed the lawn. I procrastinated, then called my doctor.

After some tests, he became alarmed. There was a widening in the thoracic aorta, and he worried it might be an aneurysm. It was late Friday afternoon, so he sent me over to the emergency room for a CT scan. Elaine joined me for some anxious waiting, and then the discovery that it was “just” a hiatal hernia. When my doctor joined us in the ER suite, we already had the news and were in full celebration mode. I announced we were going right home to have a steak, some Rocky Road ice cream, and then we were going to fool around.

He was unimpressed. "No," he said. "You passed the first hurdle, but we still don't have a good explanation for the chest pains. Monday you’ll see a cardiologist, and Tuesday you'll have a cardiac catheterization."

"Rats," said I. "I was counting on the Rocky Road."

Three of my grandparents died of cardiovascular disease. A heart attack killed my maternal grandfather at 48. My mother occasionally remarked that my grandmother had murdered him with chicken fat. A month shy of my 50th birthday, it didn't bode well.

The catheterization frightened me. But they put me under, it went off without a hitch and didn't hurt afterwards. That said, it typically takes 15-30 minutes, and they spent an hour and a half on me.

They called Elaine in after reviewing the images. The doctor was pointed. “Your husband has serious advanced cardiac disease.” She says she did a double-take, as in “Him? The healthy guy over there?”

They woke me and the cardiologist walked over. "You have a problem,” he said. “One vessel’s completely occluded and four are more than 75%. We need to do a multiple vessel CABG."I had an important business meeting coming up, and I protested for time. Elaine suddenly popped into my field of vision, pressed her nose next to mine, and said sweetly, firmly, filled with resolve, “Honey, you’re not going. You can put that out of your mind.” I knew I’d lost.

In recovery, the surgeon dropped by to introduce himself. He was pretty straightforward. “Look. You’ve had a load of crap dumped on you. We have to dig you out.” Charming or not, the metaphor drove the point home. I agreed.

They set me up for 3 days later, after the big holiday. As a parting shot, I asked the surgeon what would happen if I made love before the operation. He didn’t miss a beat. "You'll likely go out in blaze of glory."

I had a few days of anticipation. I read up on the procedure, how they'd saw my sternum in half, take a vein out of my leg, and sew me back together. They do nearly half a million of these procedures a year. The complication rate is less than 2%, lower than for tonsillectomies.

The Big Day, Elaine and I arrived at 5:30 AM for the 6:30 surgery. I undressed and they shaved me from stem to stern. This done, we had the chance for a little small talk. With nothing to do but wait, I wallowed in a little self-pity, whining aloud why I, who don't smoke, eat a good diet and am relatively fit, am going through this. An old black nurse sidled up and gave me a pitying look, "Sometimes," she said, "it just BE'S that way." Elaine meant it when she said, “That’s probably the smartest person in this hospital.”

When the anesthesiologist showed up, I told him I have friends who counseled me to ask for Versed. I said, "As long as I'm here, give me the good drugs." Elaine rolled her eyes. He smiled. Suddenly, I don't remember anything more.

Elaine says that after the Versed but before things got rolling, I sat up on the gurney. She told me to lie down, but I said I couldn't because I didn't have a pillow. Then I turned to the anesthesiologist and asked whether he followed protocols. Elaine said he started laughing, and said he did. I don't remember any of this, but I apologized later.

When I regained consciousness, one tube was down my throat and another stretched from my nose to my stomach. A clock on the opposite wall said 8:30. My hands were bound, a holdover from escape attempts a couple hours earlier. They woke me, but I struggled and tried to pull out my tubes. Later I apologized for this too. The nurses were good sports and said it happened all the time.

My bladder felt like it was going to explode. During the operation they stop your heart and transfer circulation and breathing to a machine, which infuses fluid into your system. I gained nearly 30 pounds during the operation. Elaine says I became very round, like a cartoon character.

In the confused aftermath of the surgery, I couldn't remember whether I had a bladder catheter, even though they had told me beforehand that I'd have one. A frantic internal discussion went something like this. "WOW! I really need to go! Did they put a Foley in me? They must have. Well, I'm going to let ‘er rip!" Which I did, and guiltily felt for spreading dampness that, gratefully, never materialized. It wasn't easy, but the relief was titanic.

In the first week after the procedure, you metabolize the fluid and urinate to beat the band. Once unhooked from the catheter - a blessed moment - you start tracking the fluid, and can't help being impressed by the volume.

Drained and able to focus on the larger picture, I remember thinking, "I'm ALIVE!" I really meant this, and realized I honestly hadn't expected to be here when it was done. I was exhilarated.

I turned my head to the dimming light out the window to my left and recognized the scene. This located me in space, but more importantly, convinced me that I was aware. That was comforting.

Two nurses began to bathe me, gently, firmly, and VERY thoroughly. I felt no inhibitions, and it was utterly comforting and warm. By the time they were done, I was ready to marry them.

They told me to rest. Then another woman said it would be about a half hour before they could extubate me. I nodded. This seemed like an OK idea. I could certainly be patient for a half-hour. I kept my eyes on the clock, though. About 45 minutes later they removed the tube, which makes you gag but isn't terrible. A little after that, they withdrew the nasal-gastric tube, also an improvement but a bit of an ordeal.

In addition to the bladder catheter, I had three "fire hoses" (Elaine's term) draining my chest, a central line (a large IV half the length of a soda straw) in my neck, and an IV in my hand. I was plumbed or, to use Elaine's Human Resource term, "completely outsourced."

The nurses said Elaine had waited for me to waken, but had finally gone home. She would be back first thing in the morning. I knew she'd needed the rest. I later learned that, during surgery, several friends had sat for a long while with her. One was a pal, a VP at the hospital who "just wanted to make sure that no barriers arose." Another was a retired surgeon and his wife who knew the value of comfort. Elaine doesn’t mind being alone in circumstances like this, but I was particularly glad for these kindnesses.

Elaine arrived the next morning. Early in the afternoon, a nurse arrived with a walker and told me to get out of bed, that I was going for a walk. I looked at her and asked whether she’d been doing acid. She gave me a look that suggested she wasn’t in the mood to fool around, and that I’d better get in gear. Elaine came over and we went for a walk down the hall. Considering somebody had fiddled with my ticker the day before, we both thought this was incredible.

I remained in Cardiac ICU the next 2 days. Every half hour, the nurses took measurements, made me blow into an inspirometer, wiggle my toes, roll over. I was sore and stiff, but it wasn't bad, and they gave me drugs to keep the pain in check. Now and then there was nausea or weakness, but all in all it was a breeze.

The 3rd day, I moved to a regular room. I had a lot of visitors, calls, books and magazines. My room looked like the Ituri Forest from the plants and flowers. I'd walk around the halls, and go a little farther and faster than the day before. I watched movies or read in the quiet times. Each evening, Elaine sent out a slightly smart-alecky report on my progress to a list of friends, and the following day would bring in highlights from the emails. ("Damn! Five vessels? VERY respectable!" or “Isn’t this going a little far to study the health care system?” or “Is there no end to your histrionics?!”) It was a gratifying outpouring of support, and it meant a lot for my spirits.

They spung me in the early afternoon of the fifth day. They wheeled me down to the pick-up circle, and I eased into the back seat. You avoid airbags after this type of surgery, just in case they deploy. Elaine somehow picked the bumpiest route and I felt every jolt, but soon we were home. We placed a chair in the shower, and she gave me a luxurious shampoo and a long wash. Then we took a nap in our own bed and realized we were finally home again, together, through it.

It’s seven weeks now since the surgery, and I’ve returned to my routine. It’s oddly satisfying to noticeably feel your strength return. I began a regimen by trudging around the block. That’s progressed to a brisk 3 mile walk every morning and, sometimes, another slightly shorter one in the evenings. Now I’ve added workouts at Cardiac Rehab.

People went out of their way. A few days after arriving home I looked out the window to see my neighbor Budd – a paunchy chain smoker – cheerfully mowing my lawn. I think the irony escaped him. “So don’t expect a card,” he said.

Elaine returned to work. Colleagues would drop by with extravagant lunches: tabouli with hummus, or homemade leek soup with tomato pasta on the side. The braver ones asked to see my incision – my “scratch” as the surgeon called it – and would ooh and aah appropriately.

There are phases. Body hair is slow to return, and it’s prickly. “Like sleeping with a porcupine,” was Elaine’s comment. Friends would join me for a walk, and I’d have to slow them down. There’s the day you drive again, scary but sweet with liberation. Or the moment you realize the day passed without a nap.

Normally I was buoyant, filled with the euphoria of still being alive. But there were intermittent blues too, when I was tired of not feeling like me. The psychological path is uphill and requires a purposefulness not always easy to sustain.

My 50th birthday arrived just short of 3 weeks after discharge. Once Elaine was out of the house and couldn't stop me, I drove out to the Ichetucknee River, a pristine, crystal clear ribbon of fresh water coursing through the North Florida jungle. I’ve swum this river for 35 years. I slowly swam and drifted a mile and half, watching the fish and the grasses. It was the cleansing I was looking for, and I was renewed in all kinds of ways. Arriving home, inevitable as death and taxes, and just as sobering, my AARP card was waiting.

Trauma shrinks your world, narrows your view. Early in my recovery, I was utterly disinterested in news or work. Gradually, though, I returned to my upstairs office and the world expanded again. It was organic, natural, and passed almost without notice.

All in all, it would be hard to have had a better experience. It didn't really hurt, I have a new lease on life, and I'm regaining strength daily. My family, all wonderful, stood by with a clear-eyed unwavering support. And at a time when I could really use it, I was awash in the glow of my friends' warmth and good wishes.

Could anything be better?

Dr. Klepper is a health care analyst and founder of the Center for Practical Healthcare Reform.

If you’re like me, your medical records are scattered all over your home region. (In my case, that’s lovely coastal Northeast Florida.) Over the years I’ve had several doctors: primary care physicians and specialists. I’ve been a hospital patient, and I’ve had outpatient procedures at doctor-owned facilities. I’ve had workups at several diagnostic centers and labs.

The problem is that it’s health care Babel out there. No organization has my complete history because few if any of these organizations can share my medical records. Currently less than one-quarter of doctors store their patients’ information in electronic medical records that can be traded. And even if they did, the industry hasn't defined standards for records yet, so most systems can’t talk to each other. Until recently we couldn’t grab all the pieces of a patient’s record strewn throughout a region and drop them into a single medical chart.

If I landed in an emergency room tomorrow, even if the doctors knew my name, they wouldn’t be able to retrieve my records and then factor my history into their diagnoses and treatment decisions. Instead, they’d quickly order expensive batteries of tests and, with still relatively limited information, take their best shots. No matter how skilled and dedicated they are, their clinical results would be compromised by what they don’t know. The lack of full information would drive the cost up substantially as well.

The waste associated with our inability to easily pull this information together is huge, and becomes apparent when you consider how many doctors patients see, and how little coordination among them there is. Many seniors, for instance, have regular visits with a variety of doctors. A recent national study found that, annually, the average Medicare patient saw seven different doctors in four different practices. Five were specialists.

As you'd expect, sicker patients see even more doctors. About 40 percent of seniors have seven or more chronic conditions, and typically saw 11 doctors in seven practices. The sickest 25 percent went to 16 or more doctors in at least nine practices.

Probably none of these doctors currently has access to a complete patient record. Unaware of what they don’t know, they might prescribe drugs that conflict with the patient’s other drugs, They may repeat tests recently performed elsewhere. The possibilities are endless, but the results are clear. Incomplete patient information produces poorer clinical outcomes at higher cost.

The problems I’ve described affect nearly all of us; they’re not restricted to the uninsured or the poor. Only if you receive all your care through an integrated health system, like a Mayo Clinic or Kaiser Permanente, will all your records reside in a single place. Even then, getting access to that information can be difficult if you suddenly need care elsewhere, like the emergency room of another organization.

For all these reasons, a group of community-minded individuals in my home town has been working to build a regional health information exchange. The Northeast Florida Regional Health Organization, or NEFRHO (pronounced NEF-row), would be a not-for-profit community health care utility, dedicated to a single idea: facilitating better health care information that helps everybody who touches health care – patients, employers, doctors, hospitals, health plans, our city and county officials – make better health care decisions.

NEFRHO is a Regional Health Information Organization, or RHIO. There are now RHIOs under development all over the country, simply because what they're trying to accomplish makes sense. But there are enormous challenges in getting them going. One is getting the different health care leaders within a region - they have historically been adversaries - to collaborate. The other is finding a financing model that makes it sustainable. The Healthcare IT Transition Group has a great blog that tracks the progress of these efforts around the country at http://blog.hittransition.com/rhio_regional_health_information_organization/index.html.

Several very affordable tools – we got great deals from two organizations eager to show what their tools could do when implemented community-wide - would make NEFRHO effective and financially sustainable. Carefx is a commercially available tool that translates between different electronic medical record systems around the region. A doctor types in a name and, like Google, it immediately assembles all available record information about that patient. He can see a note, a medication list, an image gathered from all the systems on the network. 

 

Think of the impact! Doctors throughout Northeast Florida would have better patient information to make better, more cost effective treatment decisions, without duplicating recently performed tests.

Another tool would help patients make better decisions about their own care, particularly important for patients responsible for an ever larger burden of their health costs. WorldDoc is an accurate and easy-to-use Web-based diagnostic tool – its being used effectively by some very progressive health plans, like Heritage, based in Houston – that helps patients determine whether they should visit their physician and what other steps are appropriate, given their symptoms. There is a personal health record, a medical encyclopedia, a tool for evaluating lifestyle health risks, comparison tools for hospital quality and drug cost, and much more.

Like any utility, NEFHRO would be sustained by very modest dues paid by its primary funders: businesses, health care organizations and local government. That support would build on our existing health care resources to create even better care than is already available in our community, and better care than is in most other communities. Imagine how companies interested in relocating would respond, in addition to our region’s many other blessings, to demonstrably better, lower cost health care.

The trick here is that we’ve designed NEFRHO to be financially self-sustaining without government or philanthropic assistance. In large part, we hope to get leverage business’ interest in WorldDoc’s capabilities to get annual dues of $15 per employee (or $1.25 per employee per month). That would make it go. In return, though, we need to document and show the returns on investment that accrue to the community and the employers.
This project already has the support of many of our hospital and physician leaders. To make it happen, all it really needs now is vision and leadership from Northeast Florida’s business and government communities.

 

If you are involved in a RHIO effort in your community, post a comment describing you experience.   Let's learn from each other.

Brian Klepper, PhD

 

 

A recently published book of the same title, by Dr. Jerome Groopman of Harvard Medical School, is a must read not only for physicians but for anybody who ever came in contact with the medical profession—and that’s all of us.

Dr. Groopman, having been himself a patient and a cancer survivor, examined in depth the sources of the all too frequent medical errors that afflict the profession. I would probably do only partial justice to his observations if I summarized the two root causes of medical errors:

1. Patient overload, and limited time to really think, yes think, about the patient and the problem at hand.
2. Partially as a result of 1, doctors make snap judgments on the basis of first impression, or gestalt.

I will cite two examples from the book.

Dr. Groopman developed pain that got progressively worse with time. He visited four orthopedic hand specialists. Mind you, they all knew Dr. Groopman as a Professor of Medicine at Harvard, so one would expect above average thoughtfulness in making a diagnosis and suggesting a course of treatment. The first one swept into the room, half-listened to the patient’s complaint, took a quick look at the hand, made the diagnosis and was ready to schedule surgery. The second and the third were essentially a repeat performance of the first one, except the diagnoses varied from the first one, and from each other's. One of those was absolutely wild; gout in the hand. Now mind you, gout is a disease where crystals of uric acid, when they reach very high concentrations in the blood, precipitate in soft tissues that are colder relative to the rest of the body. This why in 99% of the time they precipitate in the large toe, the farthest point from the heart. How did the “specialist” arrive at such a diagnosis, without even asking the patient if he had a history of gout or pain in his toe, or ordering a blood test to measure his uric acid level? Is it sheer incompetence? Maybe. But weirder things happen when your patient is the 70^th you have seen in 12 hours (about five minutes per patient). To Dr. Groopman’s question of one of the orthopedists: what if your diagnosis is wrong? The answer was astounding: no big deal, we’ll find out during surgery. Only the fourth orthopedist, who was just as pressed for time, did the obvious thing: he asked the patient to move his fingers, and observed the tendon were the pain was located.

The other specialty examined by Dr. Groopman is Radiology. “Radiology is a discipline broken down into two processes; the process of perception and the process of cognition”. This means that first the radiologist must make an observation; second, he needs to analyze what he perceives, what it means, the possible explanations for the finding. Like primary care physicians, he is at risk to miss something significant in the blur: a change in contour of a tissue or a variation in the density of an organ that he needs to notice. But the sheer volume of images a radiologist has to examine in a day’s work can easily cause a lapse in concentration. If we assume about an average of 30 seconds per image, a lapse of a few seconds can result in a missed finding and a wrong diagnosis.

Gestalt: what’s wrong with it?

Medical students and Radiology trainees are taught to systematically inspect each anatomic component on the X-ray. But radiologists are expected to look at an image and analyze it very quickly. Conclusions from first impression, or “gestalt”, are supposed to be the mark of good training. Indeed, many radiologists rely heavily on gestalt, rapidly distinguishing normal from abnormal, drawing conclusions within seconds of viewing an image.

To compound the problem, another human foible enters into the equation: the seduction of search satisfaction. If a patient is referred with the typical findings of fever, cough and yellow sputum, the radiologist’s attention is quite humanly focused on the lungs in his search for the expected pneumonia. Once the radiologist determines that the image indeed confirms the clinical findings—the temptation is to declare victory and move on.

The results.

These are not just theoretical concerns. In an interesting, and quite alarming, paper titled “Measuring performance of chest radiography” (Radiology, vol. 217, pp. 456-459, 2000), Dr. E. James Potchen and his colleagues at Michigan State University in East Lansing assessed the performance of more that 100 certified radiologists reading 60 films. When asked “is this film normal?” there was disagreement among them an average of 20% of the time. This is called “inter-observer variability”. When a single radiologist re-read on a later day the same 60 films, he contradicted his earlier diagnosis 5-10% of the time.

More remarkable: one film of the chest x-rays was of a patient who was missing his left clavicle, or collar bone. Sixty percent of the radiologists failed to identify the missing clavicle! This blindness is not a radiologist’s affliction. Psychologists identified this human tendency to focus on positive data and ignore the negative. You can find this phenomenon in the forensic field, business, and behavioral economics.

What’s to be done?

To the physicians among us the lesson is: don’t succumb to the siren song of gestalt. Look at the whole patient, listen intently to his story, and consider all the possibilities.

To the rest of us who depend on our physician’s judgment, don’t be too timid to ask: have you considered all the possibilities?

Dov Michaeli MD, Ph.D

You know that the prevention movement is gaining ground when doctors form a professional society to make “lifestyle medicine” a credentialed clinical specialty and a part of basic medical training. The American College of Lifestyle Medicine (ACLM), founded two years ago, aims to disseminate scientific research in order to encourage doctors and other health care professionals to incorporate this knowledge into their clinical practices. It also advocates appropriate reimbursement for lifestyle counseling. How about that? I say it is about time we reward docs who take the time to educate, counsel, and support patients trying to make tough lifestyle changes, such as quitting smoking or losing weight.

What I like about the ACLM is that they want to establish the scientific basis for healthy lifestyle recommendations. Right now there is a lot of noise out there with half-baked recommendations competing with those based on solid science. Dr. James Rippe, associate professor of cardiology at Tufts University School of Medicine and the editor of The American Journal of Lifestyle Medicine is quoted in an article about the College in the NY Times.  He says, “this is mainstream medicine supported by mainstream medical research”. It is not “an anti-procedure, anti-medication movement.”

In the same article, Dr. John H. Kelly, president of the ACLM, is quoted as saying,“we need to have a certification process in place with rigorous, evidence-based standards."  I wholeheartedly agree.   I believe the prevention movement will benefit greatly from having an organization, such as ACLM, work to maintain the highest standards when it comes to research and development of clinical guidelines. By sticking to the evidence, the ACLM can gain respect and adherents to prevention practice in the medical community.

So, hats off to Dr. Kelly et al for having the foresight to found this College. I, for one, am going to join.

Pat Salber, MD, MBA

 

We know that diet and exercise can prevent the onset of type 2 diabetes in people with impaired glucose tolerance. We also know that healthy lifestyle measures are more effective than even the most effective drugs. That being said, we also know that in the real world with Mickey Ds and Starbucks on every corner, long work hours, longer hours in front of the computer, and way too few hours exercising our body parts, that medications will be a part of the treatment armamentarium utilized to prevent type 2 diabetes.

So the question before us today is which drug should be used. An editorial in the March 20, 2007 issue of the Annals of Internal Medicine takes a stab at answering that question.

David Nathan, MD from the Massachusetts General Hospital Diabetes Unit and Michael Berkwits, MD, Deputy Editor of the Annals review the results of the DREAM trial (AKA, the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication trial --- seems like you can’t have an important trial nowadays without a cute acronym).

The DREAM trial randomly assigned more than 5,000 patients with impaired fasting glucose (>110 mg/dL, but less than 126 mg/dL) or impaired glucose tolerance (a glucose level 2 hours after an oral glucose load between 140 mg/dL and 199 mg/dL) into one of four groups. One group received ramipril (an ACE inhibitor), one received rosiglitazone (an insulin sensitizer), one group received both drugs, and one group received a placebo.

The participants were evaluated after 2, 6, and 12 months and annually thereafter to determine if they had either developed diabetes or died. They were also evaluated to see if their glucose levels improved during those time frames. The participants were middle-aged and they were obese (mean BMI 31 kg/m2).

Here is what the study showed:

• Participants taking the drugs had a significant reduction in the progression to type 2 diabetes
• The reduction was entirely attributable to taking rosiglitazone.
• More patients taking rosiglitazone regressed to normal blood glucose levels (almost 39% in the rosi group compared to 20% in the placebo group.
• Although both medications were generally safe, rosiglitazone was associated with a higher prevalence of peripheral edema (swollen ankles) and a ~ 2.2 kg weight gain. In addition, there was an increased frequency of heart failure in a small number of patients (0.5% in the rosi group compared to 0.1% in the placebo group)

The authors talk about what clinicians (and patients) should do in light of this new information. First of all, they point out that rosiglitazone is expensive and has some uncommon but serious side effects. There are, they remind us, other medications that have been shown to prevent progression from impaired glucose tolerance to type 2 diabetes.

Metformin is available as an inexpensive generic formulation. At least in people with BMIs of 35 or higher, the percent reduction in progression to diabetes is only slightly lower than that described with rosiglitazone (53% vs. 60%). In addition, it is well tolerated except for some minor gastrointestinal symptoms, and it is much cheaper. The other effective drug, acarbose, is poorly tolerated because of adverse GI side effects.

So what’s a clinician to do?

• Continue to counsel and support patients with impaired glucose tolerance or impaired fasting glucose to adhere to a healthy lifestyle (you know, diet and exercise).
• For patients unable to unwilling to make these changes, they recommend considering metformin, as opposed to rosiglitazone, as a medication to prevent type 2 diabetes.

It is noteworthy, that Dr. Nathan lists GlaxoSmithKline, makers of Avandia, the brand name for rosiglitazone, as a potential financial conflict of interest. His recommendation to not go with rosi as a first line diabetes prevention drug must surely have caused some heartburn in GSK marketing circles.

Pat Salber, MD

This is an interesting story to follow yesterday’s post on supply-driven demand in healthcare. The results of a WSJ Online/Harris Interactive Health-care Poll are in and they show that many Americans don’t follow their doctors’ advice. It is pretty interesting stuff.

Seventy-two percent (72%) of folks polled answered “often” or “sometimes” to the questions “based on what you know or have heard, how often do you think patients who have medical conditions experience problems because of being over-treated, for example, by getting too many treatments or by getting more aggressive treatment than is appropriate.” Only 5% of people said it never happens.

Eighty-three percent (83%) of people said patients are often/sometimes under-treated. The poll did not ask how often the respondents thought people were treated appropriately.

Only 43% of people (down from 50% in 2005) were “very” or “somewhat” concerned about overly aggressive treatment. In fact, 57% said they were not very or not at all concerned about it. Hmmm?

Thanks, but no thanks.

The poll shows that:

• 27% did not fill a prescription given to them by their doctor
• 20% sought a second opinion because they thought their doctor’s advice was too aggressive
• 13% did not get a recommended diagnostic test.
• 7% did not get a recommended surgical procedure
• And, 7% of people changed doctors because they felt their doctor’s approach was too aggressive.

And, maybe they were right

Only a handful of people who chose to forgo recommended treatment experienced any negative outcomes as a result. Two percent (2%) experienced a new medical problem or complication, 2% required hospitalization, 4% lost time from work or school, 3% went to an ED, and 3% said their health got worse. A whopping 89% said nothing negative happened as a result of ignoring their doctor’s advice.

So why do these people think docs are overly aggressive?

More than half of respondents think doctors over treat patients because they are worried about malpractice lawsuits. Forty-one percent (41%) thought docs did it to make more money. Forty-four percent (44%) were less cynical about doctor’s motives. They thought doctors were overly aggressive to meet patients’ demands. Now, here is one that is really worrisome, almost a third thought docs were too aggressive because they received misleading information form the prescription drug or medical device companies.

So what’s a doctor to do? If you are less aggressive, you might get sued. If you are too aggressive, your patient might ignore you, or worse yet, find another doctor. And, what if you get it just right? What happens then? You might get thanked. You might get paid. And you might just feel good enough about what you are doing to get up and do it another day.

Remember how shocked we were when we first heard about Dr. Moon and Dr. Realyvasquez. These are the heart doctors who performed unnecessary cardiac procedures, including coronary artery bypass surgeries, at a Tenet Hospital in Redding, California.

These guys may have been at the far end of the spectrum when it comes to driving inappropriate cardiac care, however, a study in the March 7, 2007 issue of JAMA adds to the growing body of evidence that suggests that cardiac procedure rates are strongly influenced by competitive market dynamics and not just patient need.

A group of well-respected health services researchers, led by Brahmajee Nallamothu at the University of Michigan Medical School took a careful look at the impact of introduction of specialty heart hospitals in geographic areas that represent distinct markets for tertiary (advanced) cardiac care. As opposed to general hospitals, specialty heart hospitals provide services for, and generate revenue from, a narrow spectrum of diseases.

Some health policy gurus have argued that such specialization could lead to greater efficiency and better quality of care. However, others worry that adding excess capacity could drive demand, particularly if the owners of the hospitals are doctors in that same specialty. It doesn’t take a brain surgeon to understand that filling beds, operating rooms, and catheterization labs with high revenue patients is better for the bottom line than leaving them unused.

Of course, it is possible that new specialty hospitals would just compete with existing facilities in general hospitals, taking volume from them, but keeping the overall rates of services the same. But that doesn’t appear to be what happens when one of these cardiac specialty hospitals opens in a community. Instead, the JAMA study documents that there is an incremental increase in the number of coronary revascularization procedures performed after a specialty heart hospital opens. Capacity increases and more people get these procedures.

Now this study doesn’t prove that all of this capacity was supply-driven. In fact, some of the increase may be due to meeting unfilled need. The researchers tried to understand if this was indeed what was happening by comparing what occurred when a general hospital increased its capacity compared to what happened when capacity is increased via the opening a new specialty heart hospital. What they found was a greater increase in certain cardiac procedures in communities with a new heart hospital compared to those communities with a new cardiac program at a general hospital.

Of note is the finding that there is no increase in the number of PCI (percutaneous coronary interventions) in the subset of heart patients who might benefit most from that procedure (those coming into the hospital because of a heart attack), but there was a dramatic increase in the number of PCIs being done for individuals not having heart attacks, a situation in which there may be more discretion in deciding whether to do the procedure or not.

For all of you who think, more is better when it comes to health care, I suggest you read about Drs. Moon and Realyvasquez. They had some of the highest rates of coronary procedures in the country, but some of their patients would have been better off with nothing at all.

Pat Salber