Bodo has a toothache.

man with hoe

 

In my freshman year at Amherst, all of my class took a required course in the history of Western civilization. Early in the year, the professors used the life of a fictional medieval peasant named “Bodo” as a teaching tool as a sort of baseline. Bodo was illustrated by Millet’s painting, “Man with a hoe.”  If we had taken this a bit more quantitatively, “improvement” in daily life could have been graphed as a rise in Bodo-units of happiness vs. time.

For a long time, Bodo did not get much happier. In fact, the line of the graph probably ran asymptotic to unity for centuries. The inflection point heralding the sharp rise associated with our modern life probably came somewhere after the American Civil War. When large numbers of former officers from both the Union and Confederacy who had learned the basic logistics necessary to complete very large scale tasks rejoined civilian life, amazing things happened. For instance, those logistic skills lead to the transcontinental railway and dramatic improvements in communications.

Still, the Bodo-unit graph was only rising slowly. If Bodo had a toothache, there was no local anesthesia for his dental work. His kids didn’t get shots to prevent childhood illness. He had no refrigeration, no sanitation, and no education. Then came the post-WWII boom, and the graph shot up at an incredible rate. Bodo gave up his hoe, moved to the suburbs, got a factory job, and had two kids, a dog, and a Chevy.

Just before the holidays this year, Bodo made a surprise comeback, in the form of a vigorous discussion among my classmates about a recent epidemiology paper that received substantial attention in the press. Question #1 for approaching this sort of report is always, “are the data believable?” In this case, the authors are from Princeton, and the publication is in the Proceedings of the National Academy of Sciences. The citation is: Case A, Deaton A.  Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83. doi: 10.1073/pnas.1518393112. Epub 2015 Nov 2.  Author information: Woodrow Wilson School of Public and International Affairs and Department of Economics, Princeton University, Princeton, NJ 08544.

The next important question is, “What did the researchers themselves have to say about their data?” The data showed, for the first time, increasing mortality rates in middle class whites. The entire paper is well worth reading (full free text is available on PubMed). Here’s a direct quote from the discussion. “A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a “lost generation” (36) whose future is less bright than those who preceded them.”

This is a careful, scientific conclusion, and given the data, it does not sound overly pessimistic. I spent a couple of years on the faculty at the University of Kentucky medical school; hopeless, technologically unemployed coal miners and their families were part of daily life in Lexington. Their problems are so complex as to qualify as insoluble.

In other words, the Bodo-units vs time graph does not climb upward inevitably.

This is a startling new concept that should prompt all of us to do some serious thinking. More later; for now, best wishes for the New Year.

Technology in the exam room

December 16, 2015

In the interests of full disclosure, I want to state that in my checkered past, I have belonged to a couple of interesting organizations. In my early teens, I belonged to the National Rifle Association. As a geeky kid growing up in the Midwest, I got deeply involved in competitive target shooting through a team at the local YMCA. We shot .22 caliber rimfire bolt-action “target rifles,” at standard targets at 50 feet. I was actually pretty good at it. To do this and compete in various matches, we all joined the NRA. I also avidly read “The American Rifleman,” the NRA monthly magazine and Sports Afield. After a couple of years of looking at pictures of  middle-aged men with rifles posing beside large dead furry animals, I realized that improving one’s proficiency with firearms is ultimately about doing mortal harm to other creatures. In survival situations, if one is hunting for food or part of a military conflict, I am all for proficiency with firearms. Go for it! Otherwise, not so much. My membership lapsed when I was about 14, and I’m not going to re-up now. (Yes, I do admit to some pictures of me with large fish. I am a strictly single-hook, barbless, catch-and-release fly fisherman.)

The American Medical Association is the other organization I’ve belonged to in the past, but with which I have never really come to terms. The AMA has been fairly consistent about opposing rational reform of the American health care system. Based on the historical record, the best thing that I can say for the AMA is that the organization has been even-handed. It has opposed every initiative, whether Republican (yes, both TR and Nixon supported health care reform) or Democratic (FDR, Truman, Ted Kennedy).  I joined some years ago, thinking that more academic physicians should get involved.  That was a naïve idea.

Having ‘fessed up, I hope you will understand that once on the AMA email list, a physician is on it for life. In fact, maybe longer; I can’t say yet.

So, here is a quote from one of yesterday’s (12/14) AMA Morning News stories, titled Some physicians suffering burnout over EHR mandates, “In a 1,200-word story, the Chicago Tribune discussed how the Federal government’s “elaborate – or maddening and onerous – system of electronic health records” is affecting physicians. According to the Tribune, medical associations nationwide are attributing “increasing doctor burnout to the demands of clicking through page after page of records, whether the patient shows up for a physical, a quick follow-up visit, or treatment for chronic disease.” Recently, “Mayo Clinic researchers, working with the American Medical Association, found that more than half of physicians felt emotionally exhausted.” Contributing to that exhaustion are “heavier workloads and ‘increased clerical responsibilities.’”

Now, I hope you do realize that the AMA’s default position on the federal government is not amicable. Nonetheless, I think they may have a valid point here.

The Wall Street Journal of December 14th also had a piece titled, “Is Your Doctor Getting Too Much Screen Time?” by Sumathi Reddy. The report was nicely balanced between patient and physician viewpoints, and covered both some pros and some cons. (For “fair balance,” I had a look at the New York Times, too. They did not have much objective data, but there was a terrific blog piece. 

With the AMA and WSJ articles on my mind, I went to PubMed and did a clinical search for “electronic health records patient satisfaction” and one for “electronic health records physician satisfaction.” In PubMed, overall, the patient-related citations outnumbered the physician-related citations three to one. Given publication bias (the tendency to publish positive results rather than negative findings), I suspect that the researchers make the patients’ somewhat happier with EHRs than they really are, but here are a few take-home observations.

  1. In a “similar articles” search on satisfaction with EHRs, the publications were heavily weighted toward exploring patient satisfaction. I estimate the recent ratio is about 10:1 toward patient rather than physician satisfaction.
  2. Among the few articles that looked at physician satisfaction, the highest rate of “very satisfied” physicians that I found was 38%.
  3. One telling issue was that EHR suppliers felt that their “customers” were hospital managers or practice managers, not the health care professionals using the system.
  4. American patients were concerned about “eye contact.” In contrast, European patients were concerned about data privacy.

I’m not about to jump on the podium and tell you that I know the answer to the problems of implementing EHRs into medical practice. I certainly don’t know the solution to reducing the stresses of being a physician in today’s world. But here are a few thoughts that came to me as I reflected on the data and some of my own recent visits for out-patient health care.

First, the architecture of the space in which patients and providers interact is archaic. The traditional exam room must have originated in the early 20th century. The layout certainly inhibits communication when the provider has to use electronic technology. I don’t mind sitting on an exam table, but when the exam or procedure is over, wouldn’t it be nice to get dressed and sit down beside the doctor (or nurse practitioner) for a quick discussion looking at the data together? When I went to the Cleveland Clinic for my most recent orthopedic check, Viktor Krebs reviewed the films with me on a monitor in the exam room. On a recent visit with Bawa Das, a retinal specialist here in Michigan, he showed me my fluorescein angiogram on a monitor right in the exam room. Both of these physicians are exceptional individuals, and both of them used what I would call “work-around” solutions, but they did work. Think how much easier and more effective these interactions would be if the exam rooms were actually designed with wall-mounted monitors and a work station where the patient and the provider could sit together and look at the screen!

Second, steady improvement in handwriting and voice recognition technology is likely to reduce the future “input burden” for providers, but providers are going to have to complain loudly about the burden to get the managerial classes to continue to invest in technology as it changes.

Third, we should be more concerned about personal privacy. The Europeans have legitimate concerns. (Check the NY Times blog link mentioned above for more on this.)

The bottom line? The technology is not going away, any more than the NRA or the AMA will. But, unlike our relationships with organizations where we don’t fit in, we can’t just drop out of our technologic world and make a reasonable living growing organic crops. We have to develop a reasonable degree of proficiency in using the tools, and we also have to get involved in making the technology work for us. That’s a hint to readers for further discussion…

By the way, if you found the “Hullabaloo about Drug Prices” interesting, you might want to look at “The Folly of Targeting Big Pharma: The biggest driver of rising health-care spending is the cost of labor, not drugs” by Michael Mandel in the Wall Street Journal. (Dec. 10, 2015) 

 

The drug price hullabaloo…

 

The Weekly Packet for Friday, December 11, 2015

This post comes a couple of days early. Dermatologic cancers are part of the price one eventually pays for a career in the cardiac catheterization laboratory, along with skiing, tennis, and fly-fishing. I have my third new lesion of the past 2 years, a real beauty (imagine growing a rhino horn just in front of your right ear). I’m having Mohs surgery on Friday. It’s all under local, and not a big deal, but can take quite a long time.

Campus issues at my alma mater, Amherst College in Amherst, MA, made the New York Times last week. My class of 1964, now 55 years post-graduation, has an active email list-serve (yes, kids, the old guys can adapt!) and the commentary has been spirited. Give me a bit more time on this one, though.

From time to time, “A-ha” moments come along where observations from several different settings suddenly click into place and make sense. Something along that line happened this morning while I was walking with Posie. For the past fortnight, the media have been filled with discussion about drug pricing and the rather significant bump in US healthcare costs this year. The “A-ha” went as follows.

In the disciplines of scientific and clinical research, we repeatedly tell ourselves that association is not causation. This is not true in journalism, where the process can easily be extended further to “juxtaposition implies association, and association implies causation.”

The journalists who do not do their homework would like to lead you along a path that is marked by logical, but false assumptions. A dramatic increase in the price for an off-patent drug for toxoplasmosis (Daraprim, Turing Pharmaceuticals) may be socially unjustifiable, but the incidence of toxo is not high enough for its treatment cost to impact the US healthcare budget. (See: http://www.nytimes.com/2015/09/21/business/a-huge-overnight-increase-in-a-drugs-price-raises-protests.html?_r=0 )

Here are a few facts to discuss with friends, family, and co-workers.  First, the three key drivers of US healthcare costs in decreasing order are: hospital care, physician and clinical services, and other professional services. Prescription drugs are very near the bottom of the list, just ahead of durable medical equipment. See: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf for the data.

What percentage of our health care spending goes for pharmaceuticals? The various figures range from a low of 9.7% to a high of 11.9%. The 11.9% figure comes from a reputable source, the OECD, so let’s use it, and round it off to 12%. If spending on pharmaceuticals increased a breath-taking 20%, the increase in total health care spending would be less than 2.5%. Actually, as a percentage of overall per-capital health spending, the US expenditures on pharmaceuticals are rather middle of the road. See: https://data.oecd.org/healthres/pharmaceutical-spending.htm#indicator-chart

This may be because “generics now account for 28 percent of pharmaceutical spending and 84 percent of drugs dispensed in the U.S., which is high by OECD standards.” http://www.pbs.org/newshour/updates/americans-spend-much-pharmaceuticals/. Absent the introduction of the very costly anti-hepatitis C drugs, the bill for branded drugs would probably have grown very little.

Now, to wrap up, let’s ask why the industry is getting such bad press when most of the facts don’t support it? Here, I am going to venture into opinion. I think the time has come to have some serious discussions with senior management about marketing. Here’s a direct quote from Ron Shinkman, http://www.fiercehealthfinance.com/story/big-pharmas-greed-continues-drive-healthcare-spending-and-prices/2015-02-16  “But the marketing of those [prescription] drugs has become at times questionable. John Oliver’s take on his HBO show last week was spot-on, poking fun at the young, sexy (and undereducated) pharma sales reps, the free meals and “thought-leader” designations for doctors, and the anthropomorphized bladders and other visual insanity in television commercials (Oliver was also kind enough to cite our sister site, FiercePharma). As a matter of fact, drug companies now spend more on marketing than product development. He didn’t even get into some of their even more troubling practices, such as lobbying Congress to bar Medicare from negotiating on pharmaceutical prices in bulk or buying them overseas, where the predominance of single-payer healthcare systems has forced drug companies to price their products at much lower prices.”

My take? When the ethical pharmaceutical companies ventured into “direct-to-consumer” marketing, they gave up far more than they gained. The widespread public respect for science-based companies that developed new medicines to manage or cure serious diseases was bound to crumble with “ask your doctor about (insert out drug)” followed by a list of contra-indications and adverse effects in the verbal equivalent of small print.

If those of us who work (or worked) on the scientific side of the pharmaceutical industry want to feel proud of what we do (or did), we have to realize that the industry itself has made some decisions that have not worked out well.

Welcome!

This is my first post on “The Weekly Packet.” I have three goals today. The first is to explain the site name. Simon Winchester, in his recent book Atlantic, described the development of regular mail service between North America and England. The small, fast ships that carried the packets of mail were called “packet ships,” or simply “packets.”

I’ve contended for some time that social media and the internet push us to respond too quickly to many questions. Granted, “Are you hungry?” or “Care for a glass of wine” should not require a great deal of thought. But, “why are prescription drug prices in the US higher than in Canada or the EU?” takes some mulling over before banging out a paragraph or two.

So, the idea of taking some time to reflect on issues and craft a well-thought out position brought to mind the era when substantial, hand-written letters would arrive at decently-spaced intervals. Thus, the title, The Weekly Packet,” is intended to give readers the sense of waiting at the dock with the smell of salt air and a bit of anticipation for something worth reading.

The second goal is to introduce myself. I’m Roger Mills, a retired academic cardiologist with a passion for reading and writing. I have written a fair number of articles in the peer-reviewed medical literature, as well as book chapters, and a couple of medical texts. I’m currently working on final revisions and trying to publish my first non-fiction book.

Finally, I hope to make some new contacts among the medical and scientific non-fiction writing community. I’m a newcomer, and open to suggestions and comments.

Thanks for opening “The Weekly Packet.”