I Love It When a Plan Comes Together

weeklypacket

Imagine a half-dozen or so college students in hip boots, brandishing wide nets and paper punches, invading your quiet, secure home. Fortunately, fish don’t think much at all, so the fish in the woodland pond that my ecology class visited back in 1963 probably don’t recall our visit to their ancestors, but I still do.

We set out to calculate the number of fish in the pond. The method required catching and counting a sample of fish, hence the nets. Then we marked them with a small, neatly punched hole in the thin membrane of their tails and carefully released the known number of marked fish (= M1) with detailed instructions to go and mix-and-mingle with their companions for a week. (Indicator dilution, for you purists.)

One week later, back in the hip boots, we netted a new sample and counted those with (=M2) and without (=M0) tail punch marks. With this much information, we could calculate the number of fish in the pond:
If x = number of fish in pond
Then M1/X = M2/M0 and the rest is algebra.
This was my favorite experiment in all my academic experience. Imagine getting OUTSIDE in HIP BOOTS and doing something scientific. Like a stonefly emerging from the depths of the library, I turned into an environmentalist.

Stay with me for just a few more minutes. As an almost-ten-year-old growing up in northeast Ohio, I remember the November 1952 picture of the Cuyahoga River on fire that ended up in Time Magazine a month later – a truly arresting image showing flames leaping up from the water, completely engulfing a ship. Over the years, as a physician, I’ve followed the stories of various health problems that seem to have had roots in the environment; Dan Fagin’s Toms River is one of the best. A few years ago, I first read Steven Johnson’s marvelous book, The Ghost Map, the story of John Snow and the London cholera epidemic of 1854.

Then, just this morning, I had a real “Ah-ha!” moment. I read Margaret Talbot’s New Yorker article (The New Yorker, April 2, 2018), “Scott Pruitt’s Dirty Politics,” and my son David, an environmental economist, sent me a piece from the American Public Health Association on environmental health.
“Many communities lack access to nutritious, affordable food; are denied safe           places to walk and exercise; or live near polluting factories. The health risks for these families are greater. We support research and action to help ensure healthy environments for all.”–APHA Executive Director Georges Benjamin

All of these issues are related. It all comes together!

We are not separate from the environment. In populated areas, we ARE the environment, or at least, the environment is largely man-made.

Some individuals with political power do not seem to understand the connection between environmental health —clean air, clean water, open spaces— and human health. Those individuals will not be swayed by facts. In fact, they actively reject science as a basis for public policy.

For now, we can support the public organizations that do battle on behalf of the environment, particularly those that wage their battles in the courts. And soon, we can, we should, we must…VOTE.

PS: The photo this month is an outhouse in the Chinese section of Arrowtown, New Zealand. The Chinese, who came to New Zealand as gold miners, were keenly aware of the importance of sanitation.

“Medicalization”

EPSON DSC picture
 

I have just carefully read through several editorials in the January 16, 2018 issue of JAMA, the Journal of the American Medical Association. This issue reflects a growing enthusiasm among medical editors for what’s generally called a “focus issue.”

Since I’m not an editor, I have only a vague idea of how this works. In my mind’s eye, I see the editor sitting at a very large, cluttered desk with accepted but unpublished manuscripts piled by subject. As a pile grows to a threshold size, say seven and three-quarters inches, the editor says, “Aha! A focus issue.” Then he or she gathers up the pile and says to the staff, “Print all these together in 6 or 8 weeks, and we’ll be done with them.”

Readers know that I have no intention of writing about the focus of the issue, which happened to be obesity. What I do want to reflect upon are the social changes that have moved obesity from a straightforward statement about body composition to a medical problem worthy of a focus issue of JAMA, arguably one of the most prestigious medical journals in the world.

When I was a kid, turning to a dictionary definition of the assigned subject provided an easy “out” for starting an essay. I hope I’ve become a bit more sophisticated; now, I’ll turn to Harvard Magazine instead. I quote from the issue of April 23, 2009: “There are perhaps few academic topics of equal interest to scholars of history, law, anthropology, neuroscience, and literature. But this was part of the point when scholars of these disciplines gathered on April 22 for a symposium on medicalization—a phenomenon, they argued, that has infiltrated nearly every facet of modern life.” Not exactly stirring prose, but I’m sure you see the point. Or do you?

Beginning roughly in the mid-1970s, when faced with really tough social-behavioral problems, particularly those that have serious health consequences like alcohol abuse, drug addiction, and obesity, Western society has declared them medical problems.

This process, “medicalization,” relieves broad swaths of professionals from dealing with insoluble problems. Physicians, however, seem to willingly accept the process. We seem to say, “Give us your obese, your addicted, your anxiety-ridden… Send these to my clinic, to my hospital, I lift my stethoscope beside the golden door.” Not only do we engage in this altruism, we campaign to make their diagnoses “official” and billable, and then try to find treatments.

Lest this sound a bit negative, the Harvard conference attendees catalogued the forces that help to drive the trend toward medicalization:

  • “the very existence of health insurance (costs are only reimbursable when associated with a definable medical condition
  • death certificates (the need to give a name to what caused a person’s death)
  • research funding (funding is more likely for problems defined as diseases)
  • drug trials and approval
  • and even a desire to wash one’s hands of blame for one’s condition (for instance, by considering obesity a disease that assails people rather than the result, at least in part, of one’s own actions and lifestyle).”

As I become more senior in the medical community, my awareness of the importance of communication, both among doctors and between doctors and patients, continues to grow. How long will the medical community continue to accept the process of medicalization before we say, “Look, we can help to manage the physical consequences of behavioral problems. If you are too heavy, we can replace your worn-out joints, get your cholesterol and blood sugar down, and help with your blood pressure. But we can’t modify your behavior; you have to decide to do that.”

What you see is what there is…

bfb-1-of-1

One of my medical school classmates recently posted a Washington Post article on Doximity, a “social media” site for physicians. The article caught my attention. I think it’s worthy of some comment. The author of the Post article is a brilliant young physician, Dhruv Khullar; his subject was a recent paper in JAMA by Denson, Jensen, Saag, et al. titled “Association Between End-of-Rotation Resident Transition in Care and Mortality Among Hospitalized Patients.” 

The primary finding from this large, retrospective, multicenter observational study was, “end-of-rotation house staff transition in care was associated with significantly higher in-hospital mortality.” The headline for the Post article was “When a new team takes over your care at the hospital, it can be a precarious time.” The change in titles itself is a pretty dangerous transition.

After 14 paragraphs describing the intellectual and emotional uncertainties inherent in teaching-hospital house staff transitions, Khullar finally wrote, “Patients who remain hospitalized during transitions may simply be sicker.” An editorial raising this issue, and the data in the JAMA publication from a restricted analysis that showed markedly lower mortality after attempting to adjust for the degree of illness, at last got some attention in the text.

Here’s my point. There is a critical feature that links all three pieces: the research paper, the editorial, and the Post article; they all acknowledge that the basic premise of the work is flawed, but all three then go on to propose solutions to the  undefined “transition problem” anyway.

Why do I suggest that the analysis is flawed? I’m not a statistician, but after decades of reviewing medical papers, I know enough to realize that this retrospective study was not a statistical problem of tossing fair dice. Patients who are or are not candidates for discharge from hospital on any given day differ in many ways. The study population was not randomized, and as the researchers commented, “the differences observed in patient populations might represent a direct consequence of clinical decisions made because of an upcoming transition rather than confounding. That is, if clinicians try to discharge as many patients as possible prior to transitioning off service, but have more difficulty discharging complex and long-stay patients, the average severity or complexity of patients exposed to transitions in care could be increased.”  [Italics mine]

An ad hoc attempt to adjust for these issues with an alternative approach to analysis demonstrated that the findings were highly dependent on unmeasured factors. As the researchers noted, “The increased 30-day and 90-day mortality risks observed in the main analysis suggest that the delayed discharge of these complicated patients following transition could be detrimental…   The alternative analysis, however, did not demonstrate these findings, [italics mine] which could be related to the noted differences between analyses.”

So, I would like to pose a really interesting question. Why did the authors (and the reviewers and editors) of all three pieces perceive a problem and then propose solutions to it in spite of the facts that the “adjusted” data suggested that the effect of house staff transition was not nearly as great as initially suspected, and that both the authors and the editorialists realized that, “Patients who remain hospitalized during a change in personnel on the inpatient service are likely different than (sic) those who are discharged”?

For the answer, I suggest we ask Nobel Prize winner, Daniel Kahneman. In his book, Thinking, Fast and Slow, Kahneman pointed out, “even compelling causal statistics will not change long-held beliefs…” In the transition-of-care publications authors, reviewers, and editors cling to the long-held belief that doctors can somehow overpower the poor prognosis of old age, frailty, and severe disease by improving the mechanics of healthcare delivery.

In our society, this belief encourages us to think about developing better hand-off forms for interns and residents instead of thinking about how we might really care for patients.

All’s not lost! These observational data do suggest a testable hypothesis. With an upcoming transition in care, rather than pushing early discharge for patients who are basically going to do well, a more productive approach might be to focus effort on recognizing the sicker patients and making appropriate arrangements for them, for example, earlier initiation of specialty consultations, social services for discharge planning, or consideration of hospice or palliative care transfers. In other words, one could randomize two large groups to either usual care (perhaps with the undeniably attractive hand-off forms) or pre-transition intervention starting a week or so before transitions and focused on appropriate discharge planning for sicker patients.

But then again, shouldn’t that be happening now?

P.S. The bird pictured is a blue-footed booby that Katherine photographed in the Galápagos Islands. I included it to make the point that blue-footed boobies do, indeed, have blue feet. This is directly related to the clinical concept that sicker patients do, indeed, do worse.

“Corporate Culture”

Atul Gawande, the Brigham surgeon and author, has a fascinating article titled “The Heroism of Incremental Care” in the January 23rd New Yorker magazine. His subject is the importance of good medical management over time. He writes, “Success, therefore, is not about the episodic, momentary victories … It is about the longer view of incremental steps that produce sustained progress. That … is what making a difference really looks like. In fact, it is what making a difference looks like in a range of endeavors.” He concludes that the corporate culture of healthcare must acknowledge, “The heroism of the incremental.”

The importance of careful process is a critically important subject that I tried to emphasize with house officers in training during my academic medical career. As readers of Nesiritide know, I carried that interest in process over to my work in the pharmaceutical industry as well. So, it may not surprise anyone that over a wee drop of very nice Scotch my neighbor, an upper-level manager in the automobile industry, and I fell into a talk about Volkswagen’s diesel emissions problems. I asked, “What went wrong at VW?” Which is how I ended up reading a fascinating article by Robert Armstrong in the Financial Times of January 13th.

After a review of the public-domain facts, Armstrong came to the conclusion that “something went wrong with VW’s culture such that immoral behavior became acceptable,” and he found this “an uncomfortable conclusion.” He went on, “I will confess I understand little about how corporate cultures work or how to improve them.”

Today, I talked with another friend, a businessman from Chicago, who had heart surgery at the Cleveland Clinic a few days ago. He was delighted to be feeling well and walking in the halls, but what he really wanted to talk about was the Clinic’s corporate culture. He said, “They really DO the patient-first thing here; everyone from the janitor to my heart surgeon does it.”

Corporate culture is about what the members of an organization believe about the enterprise and how they behave in both internal and external interactions. Leadership articulates the vision and values of the corporate culture and implements the practices of that culture.

I’ve been working with a group of college classmates on a project related to President Kennedy that’s driven in part by his 100th birthday this year. As President, he articulated a vision of the national “corporate culture” that asked citizens to participate in the great social enterprise. If we hope to get through the next few years, we must all get involved in defining our vision and values. Have a look at the website, watch the short video, and share your thoughts, please.

Health

I have been working, admittedly on-and-off, on a blog piece dealing with drug prices and “complementary and alternative medicine” (CAM) expenditures. Only something strange happened. The more time I spent with it, the less I liked it.

Initially, it was a reaction to a Consumer Reports article on drug pricing. As I’ve pointed out before, only a small fraction of prescriptions account for about a third of all drug spending in the US. In contrast, people spend billions every year on CAM, in the form of nutraceuticals, herbals supplements, and payments to alternative practitioners. So, it was a good case. Regulate the CAM folks, and use the savings to help pay for expensive drugs. The idea sounds like a campaign speech.

But that’s not a good case. It’s self-serving. At one level, it’s “tax the bad guys that I don’t like and give the money to the good guys who do clinical trials, aka the pharmaceutical industry.” It’s also an exercise in logical behavior that could not be expected from government. Most importantly, it completely overlooks the fact that individuals are involved in all these transactions. People, most of them very ill, find out that a drug that might help with a little relief or a little more time is extremely costly. People, often misled or ill-informed, decide to buy an herbal compound or to see a CAM practitioner. Like those of us who can’t resist a quick pick lottery ticket at the gas station, they are buying a small and short-lived parcel of hope.

As I think back to State Street Junior High, 1956, “health and physical education, third period M-W-F, Mr. Chester Riffle,” meant those were the days I carried my gym bag with shorts, T-shirt, socks, jock and a towel. Health education meant learning that if you don’t dry between your toes after a shower in the locker room, then you will get “athlete’s foot.”

As an aside, medical school is not a place to learn about health. Medical school is where you go to learn to call “athlete’s foot” by its proper name, tinea pedis. Medical school is about disease, not health.

I’m glad that I didn’t subject you to a rant about drug costs and CAM. I appreciate your patience with this alternative. Maybe, just maybe, there’s a need for a book about health. What do you think?

Signs of a health issue along I-75

Good afternoon, everyone.

The Weekly Packet will be getting back to regular sailing now that Nesiritide. The Rise and Fall of Scios has passed the final proofing and is on the way to the printer. Please look for the title as above on Amazon, or alternatively search by author: Roger M Mills, MD.

I have also been scrambling to get to a final draft of Clinical Management of Heart Failure, 3rd edition. The co-authors (Jim Young and Javed Butler) and I opted for starting the third edition with a clean slate. As a consequence, I have just made the long drive from our camp in Michigan’s Upper Peninsula to spend a day with Jim at the Cleveland Clinic. Which leads to what’s really on my mind.

On June 7th, JAMA ran an opinion piece titled “Lifespan Weighted Down by Diet” by David S. Ludwig, MD, PhD from the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital and Harvard Medical School. In response to the recent widely publicized observations of decreasing life expectancy among US counties in the Southeast and Midwest, Ludwig raises the hypothesis that technologic advances may no longer be sufficient to compensate for the adverse health effects of obesity.

He goes on to state, “Direct medical costs associated with obesity among noninstitutionalized adults have been estimated to have reached $190 billion annually in 2005, an amount that does not include losses from lower worker productivity.”

What does this have to do with driving the 495 (Mapquest) miles from Hulbert Lake to the Cleveland Clinic? Everything! With the exception of the very sparsely populated areas in northern Michigan, the trip is a visual festival of high-caloric density food. The woods and fields of the rural Midwest are blotted out by billboards for McDonald’s, Wendy’s, Kentucky Fried and scores of local places like Cops and Donuts (Clare, MI). And the drive thru lanes and parking lots for these places are packed. This observation prompted the following chain of thought.

First, I have read, learned, and written a lot about drug costs and their relationship to overall health care costs. Second, JAMA now publishes an expert from Harvard who tells us that the medical cost of obesity passed $190 billion a year a decade ago! Third, new data suggest that dietary composition may have an impact above and beyond caloric balance alone. Fourth, the fast-food industry is not about production and consumption of “high-quality proteins, fruits and vegetables, legumes, nuts, and other whole foods,” as a basic diet.

Where does this leave me? I cannot avoid the growing suspicion that some large players in the food industry are making profits by making us unhealthy, and driving the overall cost of health care up in the process. This seems at least an order of magnitude more villainous than making profits for discovering and developing new drugs to make us healthier.

One of the core values of writing the Packet was to use data to gain perspective on problems. Over the summer months, I’ll look for more data and a clearer perspective on these and other epidemiologic questions.

The Theranos evidence, waiting for a story

WFM
WFM – Undercover investigative reporter

Spoiler alert! If you already believe that you can learn more by analyzing failure than by admiring success, you can skip the rest of the post.

Because I decided to apply to medical school late in my junior year at college, in the summer of 1963, I took organic chemistry as a summer school course at Penn. I was also rowing with my life-long friend, Bernie Witholt, in a double scull at Vesper Boat Club. When the chemistry course ended, in order to keep up the rowing I needed a job and a place to live. Those very basic needs drove me to wandering through the labs in the basement of Penn’s medical school, looking for a temporary job as a lab assistant. Dr. Rita Wetton, an academic pediatrician working on hyaline membrane disease, had just said “good-bye” to her two summer assistants, and she hired me on the spot.

The next morning, I showed up in the lab, put on a white coat, and headed down Hamilton Walk to a small gate in the wall that separated the medical school from the vast grounds of the Philadelphia General Hospital. Going through, the PGH autopsy building was on my right, a non-descript squat stone outbuilding. I was there to collect fresh human lung specimens for the lab.

The dieners (autopsy assistants) seemed totally unsurprised that a college kid in a sport shirt with a white coat over it had wandered in to pick up some lungs. (At the time, I didn’t know that Dr. Wetton had a formal research agreement with the PGH pathology department.) I think they knew that they had a critical, if very basic, role in medical education. They asked if I wanted to stay and watch the autopsy that would yield the specimens. I did. So the process of looking objectively for the clues to what went wrong literally started on my very first day at medical school, months before the acceptance letter came.

As I write this, my desk is a mess. For a couple of weeks, I’ve been holding on to interesting material from the media in the hope that if I look at it carefully, objectively, maybe I can understand what happened to Theranos, the lab testing company that just a couple of years ago achieved a “value” of some $9 billion. How did Elizabeth Holmes, a Stanford drop-out with no formal medical credentials, build a corporate house of cards that is now slowly crashing under financial and regulatory scrutiny? David Crow, writing in The Financial Times magazine on April 18th, presented the facts in a very thoroughly researched article. But looking at the facts is like looking at individual organs at an autopsy, after the diener has washed them, weighed them, and put them in clean pans. What we need now is the pathologist to come in, and with knowledge and experience, he or she will tell the story that puts the facts together into a coherent narrative. At some point, the narrative may well make an instructive case study.

For now, here are just a few thoughts. A laboratory, any lab, is an attempt to reduce what information theory calls “noise.” A clinical study is a the concept of a lab built out to work in the real world. The idea of the lab is to eliminate or control variables. These can include changes in temperature, humidity, light, seismic vibration (read Black Hole Blues!), or by using inclusion/exclusion criteria and randomization, differences between groups of patients, whatever is on your list. In any lab work, reproducibility of results and documentation of methods is absolutely critical. Even so, experiments will fail; things will go wrong. That’s often when you learn that a week in the library is worth a month in the lab. It’s a painful lesson.

With her extraordinary intelligence and charm, Elizabeth Holmes seems to have believed that reproducibility and transparent documentation of methods, the fundamental steps common to both laboratory and clinical research, could be finessed. The Greeks gave that error a name; they called it hubris.

Those principles have tripped up John Darsee, William Summerlin, and many others.     But at the Theranos scale, the error has gone beyond the personal. Board members have sustained tarnished credibility, and financial supporters have lost substantial sums. And behind it all is a sad story; they didn’t do their homework. They didn’t ask to see the nuts and bolts,to subject the data to critical peer review.

The Theranos story is far from over, but it holds important lessons for all of us. We should continue to follow it closely.

Lessons from a slow start?

I’ve been saving a folded section of newspaper with Elisabeth Rosenthal’s New York Times article from February 28 on my crowded desk ( New York Times article). In it, she points out that the health care industry spent $14 billion on advertising in 2014.

Only the US and New Zealand allow direct to consumer (DTC) advertising for drugs, and I suspect (admittedly without data) that the problem is much greater in the US. You know that this is a major problem when the AMA recommends a ban on DTC ads.

Interestingly, pharmaceutical companies are not the only players in the field. Hospital advertising has increased 38% from 2011 thru 2014, to $2.3 billion a year.

Now, my industry experience has taught me that the people who decide to spend this kind of money are NOT stupid! Even if we don’t agree with their use of resources, we ought to respectfully ask, “Why are you doing this?” A hint of an answer surfaced in an unreferenced statement by Boston Globe correspondent Katherine Whittemore, who wrote that some 87% of patients who saw a drug advertised and requested a prescription for it actually received the prescription

Additional confirmation for the concept comes from an interview on NPR. “Something like a third of consumers who’ve seen a drug ad have talked to their doctor about it,” Julie Donohue, a professor of public health at the University of Pittsburgh, told NPR. “About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored.”

The answer to “Why advertise?” seems clear. “It works.” Or, at least, it has worked so far.

Now comes the really difficult question, “Is this a wise and constructive use of resources?”

Some serious thinkers believe that the era of blockbuster drugs is coming to an end. Could the dollars that have poured into advertising be re-channeled into more useful and productive activities?

I’ve just come back from the American College of Cardiology meeting in Chicago, and I think the launch of a major new heart failure compound, sacubitril/valsartan branded as Entresto, may hold some clues. Entresto had very positive phase III trial results for the management of chronic heart failure patients with impaired contractile function, and it has an engaging DTC television ad campaign, yet it has been a slow-starter. I did an entirely informal, non-randomized set of talks with colleagues to try to understand why. Two reasons emerged. First, with more and more physicians employed by large organizations, there’s pressure to hold back on “early adoption” of new agents until “the guidelines” clarify their status. Guidelines have become a huge issue. Second, generics dominate the chronic heart failure market, and because the sponsor has pegged the cost of the drug in the $400/month range there are substantial financial constraints on switching to it.

Perhaps, just perhaps, we are seeing something new and important here. Based on the available clinical trial data, I think Entresto is an important advance in heart failure treatment. But “ask your doctor about it” is not working as well as it has in the past. Maybe those advertising dollars would be better spent on another trial or two, and some physician education?

Standing at the bedside in Phase 1

Most of the folks who visit this site work in health care, either as medical professionals or in the pharmaceutical development industry. If you have not yet heard, last week a Phase 1 trial in France was complicated by five subjects experiencing very serious adverse events. One subject has died, and four others have had serious neurologic events, reportedly involving deep brain bleeds.

I had the opportunity to serve as a study responsible physician in a Phase 1 trial. The fundamental compound was a human hormone, and we had experience with it using intravenous administration. Nonetheless, we conducted a very careful Phase 1 trial with first-in-human precautions because we were administering it in a novel formulation linked to another molecule.

I went to our clinical pharmacology unit, at a center in Belgium, to be present for the first in human dosing. The setting was hardly dramatic, just a healthy young man lying on a Gurney with an IV, an automatic BP cuff, and ECG telemetry electrodes in place. An experienced study nurse gave the subcutaneous injection, and…nothing happened.

Of course, one of the six subjects in the first series would receive placebo, so on the following morning, we did it all again. Another subject, in the same setting, with another injection and … again, nothing happened. Since the arithmetic demanded that at least one of the two subjects was assigned active drug, one of the two subjects had received the very first dose of this compound ever injected into a human being.

What do you think when you are the “responsible” physician standing at the bedside for such an event? F. Scott Fitzgerald captured the experience perfectly. He wrote, “The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.” One idea is, “my goodness, we are making such a fuss over something that we know is safe.” The other, not surprisingly, is “I hope and pray that nothing goes wrong, but if it does, I hope I my emergency plan works and he will be all right.”

Our subjects were all right. But the subjects in the Bial trial were not. This is the enormous responsibility that everyone involved in research involving human subjects shoulders. Unexpectedly, despite our best efforts, something goes off the tracks.

Instinctively, we all feel sympathy for the subjects. Let’s also feel sympathy for the researchers who had high hopes for a safe and effective new drug, and were terribly, terribly wrong. We cannot brush bad outcomes under the rug. We need to talk about them, and to make sure that the lay public understands that pharmaceutical research is not a strictly commercial activity. It is a very human, and occasionally very dangerous, effort to make life better.

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)