In light of the current ALS Ice Bucket Challenge craze, came across this very interesting infographic about where we as a society donate our money and what actually kills us. Further proof of our misfearing culture.
It’s a little awkward when your first encounter with someone is pushing their butt back in.
Let’s say you live in New Jersey and find a better insurance plan across the river in New York. Sorry. You’re out of luck. But don’t worry, you’re told. Your state insurance regulators are doing their job, upholding standards and protecting your interests. Naturally, they can’t protect you in another state. So you pay more.
This makes little sense. You regularly cross the Hudson River for dinner on the town – and entrust your health to New York restaurant regulators. You drive through a tunnel and count on highway safety as regulated by New York’s Department of Motor Vehicles. But out-of-staters cannot buy insurance there. Ask yourself this: Who are those law protecting?
Jonathan Bush doesn’t directly say it, but clearly these laws are protecting insurance companies…
I’m currently reading Jonathan Bush’s new book Where Does It Hurt? and it definitely got me thinking about a lot of issues in health care. More on that to come for sure, but in the meantime a little story.
A few weeks ago, a good friend of mine had an allergic reaction to something he ate. He broke out in hives, and his face became swollen. Out of concern for his health, he visited the Emergency Department at a local community hospital. His story continues from here and highlights the failings of our health care system and questions why our system can’t and won’t perform better.
My friend spent four hours in the Emergency Department before he finally gave up and left. In the intervening four hours, he had to recount his full health history, his religious affiliation and his emergency contact information multiple times. (Anyone reading this is probably not surprised – having to recount your story multiple times is pretty much a standard when visiting a hospital.) An EKG was performed, he never actually saw a physician and the nurse assigned to take care of him was minimally present. He left without a prescription for prednisone.
After leaving the Emergency Department, he texted me in desperation asking for a prescription for prednisone. As a general rule, I don’t like writing random prescriptions for people who’s medical history I don’t actually know. My friend was desperate though because it was Sunday. His physician’s office was closed, the on call physician refused to help (a problem all in its own), and the local community health center was also closed. I finally convinced him to come to the Emergency Department at my hospital after promising to call down to the ED so his wait would be shorter and checking to see how busy things in the ED were. I’m thankful he had a good experience – though I imagine part of that was because I told colleagues in the ED that he would be showing up – but why should it be so hard? Why couldn’t the system take care of a non-life threatening medical problem on a weekend without requiring a trip to the Emergency Department?
Every aspect of my friend’s story illustrates yet another failing of the health care system. There are so many things wrong that it’s almost hard to know where to start. For example, the community hospital didn’t have access to my friend’s health records – something that likely would have decreased the number of questions he was asked in the Emergency Department. But the hospital and his primary care doctor do not share an electronic medical record, barring the hospital access to the most important information in his health history. The simple solution is a nationwide electronic medical record, so that any physician anywhere could access your health information when needed. More to come on that too.
The greater failing is that my friend couldn’t access health care outside of an Emergency Department on a weekend. But how many of us have had a non-life threatening medical event occur “after hours” and had to go to the Emergency Department to get care? You’re more likely to find a plumber or electrician available in the wee hours of the night than a physician. Health problems occur 24/7, so why has our system, and the American people, become comfortable with a medical profession that doesn’t provide 24 hour outpatient comprehensive care? When did we let the Emergency Department become the default?
In days long since gone, physicians saw their patients in their homes. Time, cost, and reimbursement concerns moved the physician visit out of the home and into a centralized office, and in the process physician hours changed. There has been some movement to change that; for medical practices to be certified as a Patient Centered Medical Home, “extended hour” appointments with “medical professionals” out of the normal work day are required – a regulation brought about by the Affordable Care Act. But that’s hardly enough incentive (and truthfully, being fully patient centered would mean going back into the home). Jonathan Bush comments in his book on the need for business outsiders to enter into the health care industry in order to change the status quo, create competition, and hopefully lower prices. These outsiders will begin by focusing on the medical system’s inefficiencies and finding ways to profit. Enter the pharmacy based clinic.
Pharmacy based clinics only came about because some smart entrepreneur or thinker at CVS and Walgreens saw an opportunity to profit off of the medical system’s inadequacies. They realized that people get sick all hours of the day, not just from 8am to 5pm, and that you can’t plan on getting sick and making an appointment. They realized that people would love having a convenient located option to get a flu shot or check for strep throat that didn’t require a doctor’s appointment, wait time, and price tag. People with chronic illnesses could easily stop at a “Minute Clinic” to have their blood pressure checked or their diabetes meds altered. After all – the pharmacy is five feet away. And CVS and Walgreens had the resources to overcome the health care system’s intense regulatory environment. Physicians initially derided these clinics as money-making opportunities headed by nurse practitioners and physician assistants with less training than physicians (with the undertone being worse quality), but we should take note. These clinics were born out of our failure as a profession to offer convenient, comprehensive service to the public.
If you argue that health care needs to change in slow incremental changes, then it’s only a matter of time before some other corporation keys into another growth opportunity in health care – and one that could have much wider reverberations and affect far more than just the physician’s office. If there’s any good news, it’s that the outsiders are slowly revolutionizing medicine, chipping away at the Berlin Wall that the status quo has for so long help up in their way. One day they will succeed in turning the industry upside down, and health care as we know it will be forever changed.
Earlier this month, well known surgeon Dr. Marty Makary wrote an opinion piece for the Wall Street Journal titled “A Minimally Invasive Approach to Health-Care Reform.” In the article, Dr. Makary touts the benefits of minimally invasive surgery as a cost-effective way of reducing health care costs in the United States. Complications following surgery cost roughly $25 billion annually, and Makary posits that minimally invasive surgery, with it’s lower overall complication rates, could save billions of dollars each year. He further notes that by avoiding larger incisions, patients spend less time in the hospital, have less pain, fewer infections, lower medication use during recovery, overall faster recovery, and lower risk of needing subsequent surgery.
However, Makary bemoans the fact that minimally invasive surgery is not the standard of care in hospitals across the United States. In fact, many patients are never even offered a minimally invasive approach. Furthermore, in a study conducted by Makary and colleagues at Johns Hopkins, they found little if any correlation between the use of minimally invasive procedures and the location, size or affiliation of a hospital. He correctly notes that the disparity likely comes from difference in culture between hospitals as well as the training of the surgeon, as some surgical training programs have heavier focuses on minimally invasive techniques. Makary continues to say that “standardizing minimally invasive and open technical training should be a priority for residency programs, rather than emphasizing on approach over the other.” He goes on to say that a hospital’s surgical outcomes should be transparent and available to prospective patients, and he even claims that a hospital’s rate of using minimally invasive surgery for specific operations should be considered a new quality measure. After all,
If there were a new medication that greatly reduced surgical infection rates, lowered pain medication use, and quickened recoveried, policy makers and health-care professionals nationwide would be asking one simple question: Why aren’t people getting it?
I agree with Dr Makary on many points in his article, but as he well knows, that question and the answers to it aren’t so simple. Dr Makary is correct with his contention that surgical training should be more standardized. Furthermore, publishing surgical outcomes and making those outcomes transparent to patients has been heavily argued for in the not so distant past – an idea that hospitals and physicians vehemently oppose and one that the Affordable Care Act is slowly trying to address through Medicare. And yes, minimally invasive techniques have an overall lower complication rate than open procedures, when performed by skilled surgeons.
But Dr Makary misses the mark on many levels, most importantly with regard to cost. First, minimally invasive techniques are more costly than open techniques; there is the added cost of specialized equipment, and in general, minimally invasive techniques take longer to perform, leading to higher operating room costs. Much of that added cost is recovered by the hospital with shorter lengths of stay and recovery times for patients undergoing minimally invasive techniques as compared to open procedures. But what Dr Makary fails to mention is that if we converted every open procedure currently being performed to a minimally invasive one (where feasible), we would certainly save money from less complications – but only if the number of procedures performed remained unchanged. Let me explain.
Minimally invasive techniques revolutionized medicine quite some time ago, with laparoscopic cholecystectomy (minimally invasive gallbladder surgery) being the best example. Prior to the introduction of laparoscopy, patients were forced to undergo painful open surgery which often necessitated hospitals days of 3-5 days or more, and the recovery time after leaving the hospitals was even longer. Open cholecystectomy was therefore reserved for patients with true emergencies; patients suffering from gallstones or biliary colic (occasional pain from the gallbladder) were told to change their dietary habits and take analgesics in order to avoid a painful operation and prolonged recovery period. Laparoscopic changed all of that by reducing risk, shortening hospitalizations, reducing pain, and decreasing recovery times. Proponents posited that despite the higher cost of performing laparoscopic cholecystectomy, the operation would greatly save money for hospitals and the health care system as patients no longer required hospitalization post procedure. They were right – but the number of gallbladder operations skyrocketed, as patients no longer wanted to deal with their gallstones and biliary colic. The result was that even though costs to hospitals decreased, overall health care costs increased due to the higher number of procedures performed. Minimally invasive approaches to nearly every other operation have likewise increased overall health care costs due to the higher number of procedures performed.
Finally, Dr Makary fails to mention that even though there may be a minimally invasive technique for a given procedure, not all operations are amenable to minimally invasive approaches. Partial colectomy (removal of a part of the colon) can be performed laparoscopically, but the minimally invasive technique is not always appropriate. And with regard to his prime example of appendectomy, the surgical literature still does not support that laparoscopic appendectomy is superior to the open technique.
There are many reasons to perform minimally invasive procedures, however, cost is not one of them. If Dr Makary’s intent is to improve the quality of care, then he’s right on the mark.
Rounding with the attendings is like a game of chess. The medical students are the sacrificial pawns that you send into battle first. The intern is like the knight and the mid-level resident is the bishop. But the main goal of everyone is to protect your queen…
… wait, I mean king!
When birthday cake is your last meal before coming to the hospital at age 84, that’s usually a sign from God.
Wait… so there are no gay rights in Louisiana?
vaccinate your kids. that’s all. Proof instead of misfearing
Originally posted on Violent metaphors:
In light of recent outbreaks of measles and other vaccine preventable illnesses, and the refusal of anti-vaccination advocates to acknowledge the problem, I thought it was past time for this post.
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It has been said that we fear that which we do not know and do not understand. But all too often, we engage in behavior known as “misfearing” – the term used to describe the human tendency to fear instinctively rather than factually. Misfearing is pervasive in our culture, and its consequences on our collective health are staggering.
In February, Dr Lisa Rosenbloom touched on the subject of misfearing with regards to women’s health in a perspective piece in the New England Journal of Medicine. A cardiologist by trade, Rosenbloom took an informal poll of her patients, asking them which health condition they thought was the number one killer of women. Many of her female patients accurately reported heart disease to be the leading cause of death for women. A fair number incorrectly said breast cancer. One of her patients, a woman with high blood pressure and high cholesterol, said “I know the right answer is heart disease, but I’m still going to say breast cancer.”
The truth is that heart disease takes the lives of more women each year than all types of cancer combined, that it is in many ways preventable, and that despite what many women believe, multivitamins and antioxidants do not reduce the risk. However, all the facts in the world cannot sway the opinion of a person who misfears, who determines their sense of risk based on not fact but feeling. Certainly, there is some amount of ignorance involved, some amount of misunderstanding from patients or a general lack of knowledge. I’m not implying that patients are not intelligent human beings, but rather physicians historically have done a particularly poor job of educating their patients. But with more and more information available to patients at their very fingertips in the nanosecond or two it takes to use Google on a smartphone, where has our collective misfearing come from?
For breast cancer, the availability of that information may be the very problem. As a society, we are constantly bombarded by health messages, and women in particular are assaulted by advertisements from groups like the Susan G. Komen Foundation, which seems to have trademarked the color pink. Women are constantly hearing about breast cancer and the importance of screening mammograms. Many physicians view a woman at age forty as beginning her “right of passage” by obtaining the first screening mammogram. There is no doubt that the message out there solidly directed at American women is to fear breast cancer, a message so pervasive that when the US Preventative Services Task Force recommended decreasing the frequency of mammography, there was a public outcry among doctors, women’s health experts, and women themselves. Rosenbloom goes on to discuss how pervasive the fear of breast cancer is in our culture, asking
Have pink ribbons and Races for the Cure so permeated our culture that the resulting female solidarity lends mammography a sacred status?
Rosenbloom goes on to create a greater argument surrounding misfearing, culture, and personal identity with breast cancer as her prime example, but misfearing is far more prevalent than only women’s health issues. Decades of research on risk perception have revealed the factors that feed our misfears, including those that are big, dramatic, memorable, or constantly on our minds. Misfearing is the reason that many of us horde guns to protect ourselves from random, senseless acts of violence that the media portrays as widespread, while we simultaneously fail to protect ourselves by buckling our seat belts. Similarly, misfearing is to blame for those who refuse to fly for fear that the plane may crash but do not realize they are far more likely to die in a car accident on the way to the local grocery store. We fear terrorists attacks and yet 15 percent of our population smokes regularly, misfearing our risks of heart disease, cancer, and stroke.
Perhaps the best example of misfearing comes from the controversy over autism and the belief that vaccines are to blame. The rising anti-vaccination movement has concluded that the dramatic increase in autism diagnoses is directly linked to childhood vaccines, citing evidence that is dubious at best and has been discredited by every respectable scientific and medical society. The same anti-vaxxer movement has been blamed for a rise in outbreaks of disease like measles and mumps, diseases that were considered eradicated in the recent past. How did this come to be? Simply put, diseases like measles and mumps have left our nation’s collective consciousness due to the incredible effectiveness of vaccines. Unlike our parents’ and grandparents’ generation, who grew up in a time when childhood disease like measles, mumps, and polio had devastating, if not deadly consequences, a new generation of parents has been immune to the highly contagious infectious diseases of our not so distant past and have instead come to fear autism’s devastating diagnosis. Despite the evidence that vaccines do not cause autism yet protect children from deadly diseases, parents continue to make the utterly baffling choice to refuse vaccines anyway. The culprit here? Misfearing – and it’s leading to a deadly public health threat.
Rosenbloom laments that there isn’t much we can do about misfearing. We can educate individuals to change the perception of their individual risk. We can craft laws and regulations based on fact rather than feeling. But while all the education and regulation in the world can sometimes nudge us toward behaviors that promote our health, they unfortunately cannot tell us what to believe. Before we can reduce our own risk, we have to believe it exists in the first place.
Ultimately, the health care we all get depends heavily on the caregivers we’ve got.
While breast and prostate cancer screening have come under fire in recent years, one bright spot in the prevention world has been colorectal cancer. The incidence of the disease, already on the decline since the 1980’s, fell a further 30% during the last decade for Americans 50 years of age or older.
Why? More colonoscopies. The number of Americans who are up-to-date on recommended colon-cancer screening rose from 55% to 65% during the past decade. The increase in screening has led to increased rates of detecting polyps, thus preventing future cancers. In fact, increased screening has translated to a drop in deaths from colon cancer as well, falling 3% per year between 2001 and 2010.
Yet there is a lot of work to do. Colon cancer remains the third most common cancer and the third leading cause of cancer deaths in the United States, after lung cancer and breast/prostate. More than 136,000 new cases, and 50,000 colon-cancer deaths, are expected this year.
When she explains something, she makes War and Peace look like a pamphlet.
I took the patient to the operating room due to peer pressure.
So last night, Orthopedics nailed the labia.
Are you a health care professional who has an interest in international health? Are you interested in improving medical care in Haiti?
Take a look at the great work being done by the METI Project. You can read about the organization, the help, and the skills they are bringing to St Luke’s Hospital in Port-au-Prince. Check out their blog to track the journeys from each of the METI teams that have already been to Haiti.
And if you are a RN, PA, PT or MD who would like to get involved, complete the online application here. http://metiproject.org/get-involved/medical-professional-application/
When the Medicaid expansion portion of the Affordable Care Act was put into place, experts and health policy wonks knew that the expanded insurance coverage for the poor wouldn’t only mean access to hospital based clinical care. After all, nearly one in five uninsured Americans between the ages of 18 and 34 and making less than 138% of the federal poverty level suffer from mental health and substance abuse disorders. In states that opt to expand Medicaid under the ACA, those people would be eligible for coverage that includes mental health treatment.
Unfortunately, states that decide not to expand Medicaid under the Affordable Care Act will leave more than 3.7 million Americans with mental illness without health-care coverage, and therefore out in the cold.
“Let’s just throw weed killer into your belly.”
“It’s like deep throating the aroma.”
“Your lack of planning is not my emergency.”
The Huffington Post yesterday pulled some data from the Commonwealth Fund about the amount of money going into Medicaid expansion. As you may or may not know, the 2012 Supreme Court ruling on the Affordable Care Act (aka Obamacare) made Medicaid expansion optional for the states. So far, 20 states have opted out of expansion (although a few are renewing their push to expand).
It turns out that rejecting expansion also means rejecting billions of dollars in federal funding. Two of the states that would have benefited the most? Texas and Florida, who stand to lose more than $9 billion and $5 billion, respectively, by 2022. If there was anything to make a political campaign on… this just might be one of them…